Her Story: Recovery Beginnings Application

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Please fill out the information requested below and we will get back to you within 24 hrs.

Email *

Your Name *

Is this application for: *

YOURSELF

SOMEONE ELSE

Client's Name *

If you are applying on behalf of someone else, please explain your relationship and whether or not she is willing to get help.

Birthdate *

YYYY

Zip Code *

Ethnicity *

Hispanic or Latino

Non-Hispanic or Latino

Prefer not to answer

Phone number *

Are you currently employed? If yes, where at? *

What is your current living situation (homeless, with friends, etc.)? *

What substances are you currently using (heroin, cocaine, etc.)? *

When was the last time you used? *

List past treatment or recovery programs, if any. *

Do you currently have a sponsor? *

Do you have any Court, Probation or Children's Services cases that are currently open? If yes, what county are your services in? *

Do you have any past or current mental health diagnosis? If yes, please provide your diagnosis. *

Do you have insurance, if yes, please include your provider: *

Do you have any history of Suicidal Ideations? *If you are currently experiencing a mental health crisis, please call 911 or go to your nearest Emergency Room. *

Are you currently experiencing any of the following symptoms? *

Fever

Shortness of Breath

Diarrhea

Loss of Taste

Muscle or Body Aches

Congestion or Runny Nose

Headache

Fatigue

Cough

None of the Above

Required

Are you currently on any medications? If yes, please list them. *

What do you hope to accomplish by coming to Her Story? *

How did you hear about us? *

Please share anything else you would like us to know.

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of Her Story, INC.. Report Abuse

Forms