Name *

First Name

Last Name

Date of Birth

MM

DD

YYYY

Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Are you currently employed?

Yes

No

Are you able or do you have assistance to afford the program fees associated with Hiawatha House?

Yes

No

Do you believe you need detoxification?

Yes

No

Are you currently in treatment for substance use (Therapy, PHP, IOP)?

Yes

No

Sobriety date

MM

DD

YYYY

Do you have a sponsor?

Yes

No

Do you or are you open to working a 12-Step Program?

Yes

No

Have you been tested for HIV?

Yes

No

Have you been tested for Hepatitis C?

Yes

No

Do you agree to store your medications according to our medication storage policy and procedure during your stay with us?

Yes

No

Do you agree to take your medication as prescribed?

Yes

No

Do you agree to not disclose your medications to other residents?

Yes

No

Have you traveled out of the country in the last 30 days?

Yes

No

Have you come in contact with anyone with an infectious disease?

Yes

No

Have you had a fever in the last 30 days?

Yes

No

Have you been tested for COVID-19?

Yes

No

Date of last COVID-19 test:

MM

DD

YYYY

Any history of harm to yourself or another?

Yes

No

Are you court-ordered to sober living or on probation?

Yes

No

Are you a registered sex offender?

Yes

No

Are you on community control?

Yes

No

Are you on house arrest?

Yes

No

Today's date

MM

DD

YYYY