Application for Residential Services at New Hope Manor

APPLICANT INFORMATION

Last Name:First Name: Middle Initial:

Maiden Name:

Gender: ___Male   ___Female   ___Transgender  

Date of Birth: _________________   SSN: _______-_______-_____________

Your Phone #: (_______)________-_____________    May we leave a message?:  ___ Yes   ___No

Current Address: ___________________________________________________________________

  1. 1.Please check your housing situation at the time of this application:

___Homeless___Private Residence ___Other (Describe):

___Living in Shelter___Other OASAS/OMH Residence

___Correctional Facility___Hospital/Inpatient Rehab

  1. 1.Do you inject non-prescribed drugs using a needle/syringe?    ___ Yes   ___No

  2. 2.Are you pregnant at this time?  ___ Yes   ___ No

CURRENT SERVICE PROVIDER INFORMATION

Please provide the information below for the service(s) you presently receive

Inpatient Rehab/Stabilization:Phone: (_____)_____-______

Counselor Name: Fax: (_____)_____-______

Outpatient Substance Use Treatment: Phone: (_____)_____-______

Counselor Name: Fax: (_____)_____-______

Inpatient Mental Health Agency: Phone: (_____)_____-______

Counselor Name: Fax: (_____)_____-______

Outpatient Mental Health Agency: Phone: (_____)_____-______

Counselor Name: Fax: (_____)_____-______

Care Management Agency: Phone: (_____)_____-______

Counselor Name:Fax: (_____)_____-______

Primary Care Physician: Phone: (_____)_____-______

Address:Fax: (_____)_____-______

Other Health Provider:Phone: (_____)_____-______

Address:Fax: (_____)_____-______

Other Provider: Phone: (_____)_____-______

Address: Fax: (_____)_____-______

*PLEASE ATTACH THE FOLLOWING

OR HAVE YOUR MOST CURRENT PROVIDER SEND THIS INFORMATION*

ATTACHED

  1. 1.Most recent Psychosocial, Comprehensive and         ___ Yes   ___No

Psychiatric Evaluation for substance       

use and mental health disorders with DSM Diagnosis.               

  1. 1.Most recent History and Physical        ___ Yes   ___No

  2. 2.Most recent laboratory results including CBC Complete Blood Count and Differential, Urinalysis, UDS Urine Drug Screen.          ___ Yes   ___No

  3. 3.Most recent (Must be within the past year)                      ___ Yes   ___No

TB (Tuberculosis) Test (PPD or Chest X-Ray)

  1. 1.Consent for Release of Information Between        ___ Yes   ___No

Current Service Provider and Residential provider.

  1. 1.LOCADTR Assessment (Level of Care Determination)       ___ Yes   ___No

  2. 2.Copies of Photo ID, SS Card, Birth Certificate         ___ Yes   ___No

Insurance Card.

*If you have not had a history and physical, the required lab work, and/or TB screening done within the past 12 months, please schedule them immediately**

Please answer yes or no to the following statements

  1. 1.I need services for my substance use disorder. ___ Yes   ___No

  2. 2.I believe that I am free of any communicable (infectious)___ Yes   ___No

disease that can be spread by ordinary contact.

  1. 1.I believe that I need acute (immediate) hospital ___ Yes   ___No

care right now. (IE: In need of immediate medical or

psychiatric care that can only be managed in a hospital setting.)

  1. 1.I have thoughts of hurting others or myself at this time. ___ Yes   ___No

  2. 2.I have a history of seizures. ___ Yes   ___No

  3. 3.I am currently prescribed methadone. ___ Yes   ___No

Rent/Payment

Insurance Information

What Health Insurance do you currently have? (Medicaid, Private Ins., Medicare etc.): _______________________________________   Insurance # or CIN #: _______________________

Are you covered by a Managed Care provider? (Fidelis, MVP, CDPHP etc.):

_______________________________________   Managed Care ID#: _________________________

Wages/Other Income

Please provide monthly income including a pay stub. Monthly Income $ _________________________

Please check source of income: ___ Family   ___Wages   ___Unemployment   ___ Pension   ___Trust Fund

*If you do not have any wages/SSD/SSI or other income, please apply for TA/Cash Assistance Immediately

DHS Funding-Temporary Assistance

I applied for full cash assistance (Housing/Rent) on: Date: ____________________

SSI/SSD

Please check the type of social security you are receiving:    ___SSI    ___SSDI

Please provide monthly SSI/SSDI income. Monthly SSI-SSDI income $

DESCRIPTION OF RESIDENTIAL SERVICES FOR WHICH YOU ARE APPLYING

Rehabilitative Services in a Residential Setting: I need a 24-hour supervised setting to successfully maintain abstinence, participate in treatment, and achieve lasting recovery in a structured setting.


***In signing this application I am agreeing that all information in the documents being submitted is factual***


Signature of Applicant (Person seeking residential services): _______________________________________

Date: ___________________________