Lynden Human Life application

Great Expectations

Please answer every question to the best of your ability. The questions may seem very personal in nature, but it is our desire to know you and help you as much as possible.

IDENTIFICATION

1. Name: ___________________________________ Date of Birth:___/___/______

Last First Middle MM / DD / YEAR

Maiden Name: _________________________________

2. Address: ____________________________________________________________

Street City State Zip

3. Social Security Number ________________________________________________

4. Do you have a driver's license? Y / N

Driver License Number _______________________________State _____________

EMERGENCY CONTACT

1. In case of emergency, notify: ____________________________________________

Relationship ______________________________ Phone _____________________

Address ____________________________________________________________

Street City State Zip

2. Other important contacts person(s) and numbers:

___________________________________________________________________

3. Do you have any health insurance or medical assistance - such as Medicaid? Y / N

Policy ___________________________ Policy Number ______________________

PERSONAL INFORMATION

1. Where are you currently living? __________________________________________

With Whom Where

3. Home Phone ______________________ Cell Phone_________________________

3. Pregnancy Due Date ___/___/______

2. Social Worker's Name _______________________________ Phone ____________

3. Are you an American citizen? Yes_____ No_____ Naturalized? ________________

4. Are you eligible for and/or receiving: Welfare, Unemployment compensation, SSI,

Disability, Workman's compensation or other income? Explain _________________

____________________________________________________________________

If no, how are you supported? ____________________________________________

5. Marital Status: Single___ Married___ Separated___ Divorced___ Remarried___

Spouse (Full Name): __________________________________________________

Address of (Ex) Spouse: _______________________________________________

Date of Marriage: ___/___/______ Spouse's Date of Birth: ___/___/______

Spouse or Ex-Spouse's Occupation_______________________________________

If divorced/separated, please give date: ___________________________________

Reason for breakup ___________________________________________________

6. Do you currently have a boyfriend? Y / N Name:___________________________

Boyfriend's Date of Birth: ___/___/______

7. Name of baby's father: ______________________________________ Age______

If not listed above, what is baby's father's date of birth: ___/___/______

Does he know about your pregnancy? Y / N

If yes, how does he feel about it? ________________________________________

___________________________________________________________________

How does he feel about you coming to Great Expectations? ___________________

___________________________________________________________________

8. Describe your relationship with your husband/ex-husband/boyfriend/baby's father

___________________________________________________________________

9. Do you have other Children? Yes_______ No_______

CHILD'S NAME AGE OTHER PARENT'S NAME SUPPORT

Me Other

10. Education/training: Highest grade completed? _____________________________

G.E.D.? ____________________________________________________________

Do you have any learning disabilities? Please explain: ______________________

__________________________________________________________________

11. Do you have any outstanding debts? Explain (To whom do you owe? What

amount?) __________________________________________________________

12. Have you ever been involved in prostitution? Y / N If yes, how long? _________

PARENTAL FAMILY HISTORY

1. Parent's marital status: Married ___ Separated ___ Divorced ___ Remarried ___

_____________________________________________________________________

Mother's Name (Stepmother if applicable) Home Phone

_____________________________________________________________________

Address Work Phone

_____________________________________________________________________

Father's Name (Stepfather if applicable) Home Phone

_____________________________________________________________________

Address Work Phone

2. As a child, did you feel closest to: Father ____ Mother ____ Other _____________

3. When did you last see them, and when did you last live with them? ______________

___________________________________________________________________

4. Answer the following, describing your parents/guardians:

Still living? ........................................ Father _____________ Mother ____________

Alcoholic? ........................................ Father _____________ Mother ____________

Substance abuser? .......................... Father _____________ Mother ____________

Religious affiliations? ………………. Father _____________ Mother ____________

Christians? ....................................... Father _____________ Mother ____________

How often do they attend church? … Father _____________ Mother ____________

Occupations? ................................... Father _____________ Mother ____________

5. If you were raised by anyone other than your own parents, briefly explain: ________

___________________________________________________________________

6. How would you describe your current relationship with your father? ______________

___________________________________________________________________________

7. How would you describe your current relationship with your mother? ____________

___________________________________________________________________

8. How many brothers and sisters do you have? _______________________________

How many older brothers? _________________ Sisters?____________________

How many younger brothers?_______________ Sisters? ___________________

9. What is your current relationship with your siblings? _________________________

___________________________________________________________________

HEALTH HISTORY_&_INFORMATION

1. What provisions have been made for your medical/dental expenses? ____________

___________________________________________________________________

2. Do you have any physical conditions or disabilities that would inhibit normal

manual labor? Y / N Please explain __________________________________

3. Would you give consent to doctors or agencies involved in previous treatment to

release confidential information to Great Expectations if we were to ask you to do so? Y / N

4. Do you have any allergies? Y / N List: ___________________________________

___________________________________________________________________

5. List any and all medication that you take:

Medication Dosage Reason For How Long

__________ ___________ ____________ __________

EMOTIONAL AND BEHAVORIAL HEALTH INFORMATION

1. Have you ever been sexually abused? ........ Yes ___ Maybe ___ No ___

Have you ever been physically abused? ..... Yes ___ Maybe ___ No ___

Have you ever been emotionally abused? ... Yes ___ Maybe ___ No ___

Have you ever been neglected? ...................Yes ___ Maybe ___ No ___

If you were mistreated, was it reported? Y / N

If yes, where was it reported? Was it Investigated?__________________________

___________________________________________________________________

2. To what degree have you experienced or engaged in the following behaviors?

(1)Never - (2)Rarely - (3)Sometimes - (4)Regularly - (5)Very Often

Sexual Offending 1 - 2 - 3 - 4 - 5 Court Involvement 1 - 2 - 3 - 4 - 5

Fire Fascinated 1 - 2 - 3 - 4 - 5 Fire Setting 1 - 2 - 3 - 4 - 5

Physical Violence from Adults 1 - 2 - 3 - 4 - 5 Physical Violence toward Kids 1 - 2 - 3 - 4 - 5

Physical Aggression toward Adults 1 - 2 - 3 - 4 - 5 Physical Aggression from Kids 1 - 2 - 3 - 4 - 5

Suicidal Thoughts 1 - 2 - 3 - 4 - 5 Openness to Parents 1 - 2 - 3 - 4 - 5

Suicidal Attempts 1 - 2 - 3 - 4 - 5 Openness to Peers 1 - 2 - 3 - 4 - 5

Drug Use / Abuse 1 - 2 - 3 - 4 - 5 Alcohol Use / Abuse 1 - 2 - 3 - 4 - 5

Running Away 1 - 2 - 3 - 4 - 5 Skipping School 1 - 2 - 3 - 4 - 5

Gang Associations 1 - 2 - 3 - 4 - 5 Keeping Friends 1 - 2 - 3 - 4 - 5

Pornography 1 - 2 - 3 - 4 - 5 Shoplifting / Stealing 1 - 2 - 3 - 4 - 5

3. Please summarize emotional and behavioral health concerns: __________________

____________________________________________________________________

Have you ever been diagnosed or treated for: DID/Dissociate Disorder ___ ADHD ___ ADD ___ Schizophrenia ___ Bi-Polar Disorder ___ Borderline Personality Disorder ___

DRUG HISTORY

DRUGS USED YOUR AGE ROUTE OF ADMISSION

First time Last time (Sniffed, Oral, Other) How often?

Alcohol

Barbiturates/downers

Amphetamines/uppers

Heroin

Cocaine

Hallucinogenic

Opium

Crack

Tobacco

Marijuana

Methadone

Others (specify)

1. I depend on drugs: (Check to ones that apply to you)

____ To cope with life ____ To be "in" with the crowd

____ For pleasure ____ Other

____ To escape reality

2. Longest period clean __________________________________________________

LEGAL HISTORY

1. Have you ever been arrested? Y / N How many times? ____________________

DATE CHARGES CONVICTED SENTENCE TIME IN JAIL

Y N

2. Have you ever been on probation? Y / N Are you currently on probation? Y / N

How long? _________________________Time remaining? ___________________

How often do you report? ___________________ In person, by mail? ___________

3. Name of Probation Officer: _____________________________________________

Address: ______________________________________ Phone: ______________

4. Have you served time in prison? Y / N

When? _______________________ Where? ______________________________

5. Are you on parole? Y / N How often do you report? ________________

Name of Parole Officer ________________________________________________

Address: ____________________________________Phone: _________________

6. Name of Lawyer: _____________________________________________________

Address: ______________________________________ Phone: ______________

SPIRITUAL LIFE

1. Have you ever committed your life to God? Yes ____ No ____ Date ____________

2. What were the circumstances that led to this commitment? ____________________

______________________________________________________________________

3. Denominational preference (if any) _______________________________________

4. How often did you attend church? Never _____Occasionally ____ Regularly _____

5. Are you a member of any church of religion? _______________________________

6. Did you attend church as a child? _________ What Church? ___________________

7. How old were you when you stopped attending? ____ Reason? ________________

8. Have you been involved in any of the following? (Please circle all that apply)

Ouija Boards - Palm Reading - Séances - Horoscopes - Satan Worship - Divining

Fortune Telling - Witchcraft - Spell casting - Voodoo - Yoga - Other ___________

PROGRAM HISTORY

1. Have you ever been in a program before?

PROGRAM NAME DATE CITY & STATE REASON FOR LEAVING

2. What do you see as your greatest needs, in order of priority? __________________

_____________________________________________________________________

3. Do you feel like you are ready for a change in your life? _______________________

_____________________________________________________________________

EMPLOYMENT

1. What is your trade/profession, if any? _____________________________________

2. Name of last employer _____________________ Type of work ________________

3. How many different jobs have you held in the last year? ______________________

Reason for leaving? __________________________________________________

4. What are your work skills? ______________________________________________

5. What kind of trade would you like to learn? _________________________________

6. What career interests do you have for the future? ____________________________

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

I acknowledge all the information I have entered is correct: _____________________________

Signature Date