Admission Application

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Once you have started this form you may choose to save it and return to filling it out at another time.

Simply click SAVE and the form will be emailed to the address you provided.

To resume, click the link in the email you receive and open the application on our website that you wish to complete. It will return you right where you left off.

Demographic Information

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Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Current Contacts

Item {binding ItemNumber}

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Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Provider Information

Item {binding ItemNumber}

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Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Entitlements Information (Insurance)

Item {binding ItemNumber}

Alongside this application, please send us a copy of both sides of applicants insurance card. 

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Entitlements Information (Income)

Item {binding ItemNumber}

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Hospital Episodes and/or Mental Health and Addiction Treatment History

Item {binding ItemNumber}

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Current Diagnosis Information

Item {binding ItemNumber}

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Current Allergy Information 

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We strive to provide nutritious meals to the best of our ability. We do not offer specialized individual meal plans. We cannot guarantee the absence of cross-contamination in our foods. 

Medication Information

Item {binding ItemNumber}

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Immunizations - Yes, I have had the following.

We encourage all guests to have had a tetanus shot within the last 5 years. 

Tetanus {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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TB {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Alcohol and Substance Use Information

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I use {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Average Amount {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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I use {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Average Amount {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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I use {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Average Amount {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Have you ever been told by a friend/family member or provider that you have a problem with alcohol or substances? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Other compulsive behaviors {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Family History

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Social Support

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Legal Status and Legal Involvement History

Does Person Served have a Legal Guardian, Rep Payee or Conservatorship? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Does the person have a history of, or currently involved with the legal system (i.e., legal charges)? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Physical Health Summary

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Does person wish to consider using complimentary health approaches and want help finding a provider?  {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Trauma History

Does this person report a history of trauma? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Person Served Strengths / Abilities / Resiliency

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{# pageNumbers}

Admission Application

Once you have started this form you may choose to save it and return to filling it out at another time.

Simply click SAVE and the form will be emailed to the address you provided.

To resume, click the link in the email you receive and open the application on our website that you wish to complete. It will return you right where you left off.

Demographic Information

Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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Email {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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Home Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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Cell Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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Other Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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Birthdate {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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Social Security No: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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Gender Identity {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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Referred By {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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Employment Status {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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Education Status {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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School Name (if currently enrolled) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Current Contacts

Item {binding ItemNumber}

Contact Type {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Relationship {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Email {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Provider Information

Item {binding ItemNumber}

Type of Provider {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Email {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Entitlements Information (Insurance)

Item {binding ItemNumber}

Alongside this application, please send us a copy of both sides of applicants insurance card. 

Upload insurance card images {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Insurance Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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ID Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Private Insurance Group ID {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Private Insurance Group ID {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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ID Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Effective Start {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Expires {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Self Pay/Co Pay Amount {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Entitlements Information (Income)

Item {binding ItemNumber}

Income Source {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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ID Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Amount {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Effective {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Expires {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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Payee?? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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Hospital Episodes and/or Mental Health and Addiction Treatment History

Item {binding ItemNumber}

Admission Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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Treatment {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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Hospital/Facility {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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Hospital/Facility Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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Reason/Outcome {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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Efficacy of past and current treatment {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Additional Psychiatric History Details {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Current Diagnosis Information

Item {binding ItemNumber}

Condition {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Onset Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Diagnosis Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Current Allergy Information 

Item {binding ItemNumber}

Allergen {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Reaction {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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Severity {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Status {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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Onset Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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Digital Record {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Dietary Restrictions {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Medication Information

Item {binding ItemNumber}

Medication {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Start Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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Strength {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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Dosage {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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Frequency {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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Immunizations - Yes, I have had the following.

We encourage all guests to have had a tetanus shot within the last 5 years. 

Tetanus {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Date last given {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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TB {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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Date last given {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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Alcohol and Substance Use Information

Alcohol Use:  {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Date of last use {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
I use {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Average Amount {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Substance Use: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Date of last use {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
I use {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Average Amount {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Tobacco Use {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Date of last use {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
I use {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Average Amount {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Have you ever been told by a friend/family member or provider that you have a problem with alcohol or substances? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Other compulsive behaviors {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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If Other, please explain: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Family History

Family History and Relationship, Parental/Familial Caretaker Obligations: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Pertinent Family Medical, Mental Heath, and Substance Use History: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Developmental History and Status: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Social Support

Friendship/Social/Peer Support Relationships, Pets, Community Supports/Self Help Groups (AA, NA, SMART, NAMI, Peer Support, etc.): {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Religion/Spirituality and Cultural/Ethnic Information: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Legal Status and Legal Involvement History

Does Person Served have a Legal Guardian, Rep Payee or Conservatorship? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Is there a need for a Legal Guardian, Rep Payee or Conservatorship? If yes, please explain: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Does the person have a history of, or currently involved with the legal system (i.e., legal charges)? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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If there is a history or current involvement with the legal system, please explain: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Physical Health Summary

Does the person use complimentary health approaches (e.g. natural products, mindbody practices, yoga)? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Does person wish to consider using complimentary health approaches and want help finding a provider?  {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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If yes, please describe: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Trauma History

Does this person report a history of trauma? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Please explain: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Person Served Strengths / Abilities / Resiliency

Personal Qualities: (Examples: open, friendly, engaging, motivated, loyal, resourceful, caring, thoughtful) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Living Situation: (Examples: has maintained long-term stable housing, gets along with living companions) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Financial/Employment/Education: (Examples: graduated HS, attended college, currently working, hx of working, multiple work skills) Un {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Health: (Examples: consistent good health, exercises regularly, self-cares for health issues as directed by physician, eats nutritional foods) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Leisure/Recreational/Community Involvement: (Examples: sports, belongs to social group, attends the gym, volunteers for Red Cross) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Natural Supports: (Examples: family members, clergy, close friends, neighbors, advisors) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Spirituality/Culture/Religion: (Examples: enjoys religious services, participates in cultural events, meets regularly with Rabbi) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
If there are is any additional information that will help us in the admission process, please use the space below to write a brief narrative. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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The email has been sent.

Your progress has been saved.

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Admission Application

Once you have started this form you may choose to save it and return to filling it out at another time.

Simply click SAVE and the form will be emailed to the address you provided.

To resume, click the link in the email you receive and open the application on our website that you wish to complete. It will return you right where you left off.

Demographic Information

Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Email {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Home Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Cell Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Other Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Birthdate {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Social Security No: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Gender Identity {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Referred By {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Employment Status {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Education Status {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
School Name (if currently enrolled) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
{ binding firstError.message }

Current Contacts

Item {binding ItemNumber}

Contact Type {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Relationship {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Email {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
{ binding firstError.message }

Provider Information

Item {binding ItemNumber}

Type of Provider {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Email {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
{ binding firstError.message }

Entitlements Information (Insurance)

Item {binding ItemNumber}

Alongside this application, please send us a copy of both sides of applicants insurance card. 

Upload insurance card images {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{{ Cognito.resources['fileupload-dropzone-message'] }}
{binding Name, mode=oneTime}
{binding Description}

{ binding firstError.message }
Insurance Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
ID Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Private Insurance Group ID {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Private Insurance Group ID {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
ID Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Effective Start {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Expires {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Self Pay/Co Pay Amount {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
{ binding firstError.message }

Entitlements Information (Income)

Item {binding ItemNumber}

Income Source {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
ID Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Amount {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Effective {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Expires {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Payee?? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
{ binding firstError.message }

Hospital Episodes and/or Mental Health and Addiction Treatment History

Item {binding ItemNumber}

Admission Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Treatment {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Hospital/Facility {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Hospital/Facility Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Reason/Outcome {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
{ binding firstError.message }
Efficacy of past and current treatment {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Additional Psychiatric History Details {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }

Current Diagnosis Information

Item {binding ItemNumber}

Condition {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Onset Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Diagnosis Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
{ binding firstError.message }

Current Allergy Information 

Item {binding ItemNumber}

Allergen {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Reaction {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Severity {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Status {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Onset Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Digital Record {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
{ binding firstError.message }
Dietary Restrictions {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }

Medication Information

Item {binding ItemNumber}

Medication {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Start Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Strength {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Dosage {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Frequency {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
{ binding firstError.message }

Immunizations - Yes, I have had the following.

We encourage all guests to have had a tetanus shot within the last 5 years. 

Tetanus {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Date last given {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
TB {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Date last given {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
{ binding firstError.message }

Alcohol and Substance Use Information

Alcohol Use:  {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Date of last use {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
I use {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Average Amount {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Substance Use: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Date of last use {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
I use {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Average Amount {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Tobacco Use {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Date of last use {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
I use {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Average Amount {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Have you ever been told by a friend/family member or provider that you have a problem with alcohol or substances? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Other compulsive behaviors {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
If Other, please explain: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
{ binding firstError.message }

Family History

Family History and Relationship, Parental/Familial Caretaker Obligations: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Pertinent Family Medical, Mental Heath, and Substance Use History: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Developmental History and Status: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }

Social Support

Friendship/Social/Peer Support Relationships, Pets, Community Supports/Self Help Groups (AA, NA, SMART, NAMI, Peer Support, etc.): {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Religion/Spirituality and Cultural/Ethnic Information: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }

Legal Status and Legal Involvement History

Does Person Served have a Legal Guardian, Rep Payee or Conservatorship? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Is there a need for a Legal Guardian, Rep Payee or Conservatorship? If yes, please explain: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Does the person have a history of, or currently involved with the legal system (i.e., legal charges)? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
If there is a history or current involvement with the legal system, please explain: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }

Physical Health Summary

Does the person use complimentary health approaches (e.g. natural products, mindbody practices, yoga)? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Does person wish to consider using complimentary health approaches and want help finding a provider?  {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
If yes, please describe: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }

Trauma History

Does this person report a history of trauma? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Please explain: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }

Person Served Strengths / Abilities / Resiliency

Personal Qualities: (Examples: open, friendly, engaging, motivated, loyal, resourceful, caring, thoughtful) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Living Situation: (Examples: has maintained long-term stable housing, gets along with living companions) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Financial/Employment/Education: (Examples: graduated HS, attended college, currently working, hx of working, multiple work skills) Un {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Health: (Examples: consistent good health, exercises regularly, self-cares for health issues as directed by physician, eats nutritional foods) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Leisure/Recreational/Community Involvement: (Examples: sports, belongs to social group, attends the gym, volunteers for Red Cross) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Natural Supports: (Examples: family members, clergy, close friends, neighbors, advisors) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Spirituality/Culture/Religion: (Examples: enjoys religious services, participates in cultural events, meets regularly with Rabbi) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
If there are is any additional information that will help us in the admission process, please use the space below to write a brief narrative. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }