YWCA Hawley House

Our Mission

Application

By completing the form below, you are comfirming that you are officially seeking acceptance to the YWCA Hawley House and you understand that you must have a minimum of four days of total abstinence from alcohol and drugs before you can be accepted into the program.

Name *
Date *
Have you ever applied to Hawley House before? *    
If YES when?
Have you been a resident before? *    
If YES when?
Date of Birth *
Age *
Gender *    
Ethnicity
Current Address *
City *
State *
Zip Code *
Telephone *
Who referred you to Hawley House? *
What is their name?
Phone Number
What is the name of the Agency/Hospital/Community Program that they represent?
Phone Number
County
Do you have a drivers license? *    
Do you have a photo ID? *    
Marital Status *
Do you have any children? *    
Who has custody of them?
Do you have visitation with them?    
What is your education history?
(ex. High School, GED, College) *
Describe why you are seeking services at Hawley House
500 character limit
What are your goals? *
500 character limit

Criminal History/Status
Have you ever been charged or convicted of a violent or sex-related crime? *    
If so, please explain when and what happened
500 character limit
Do you have any pending charges? *    
If yes, list of offence(s)
Expected court date(s)
Do you have an attorney?    
Name of Attourney
Phone of Attourney
Have you ever been incarcerated?    
If yes, name the jail or prison facility
Last court date
Date of expected release
Probation? *    
Parole? *    
Type of Probation or Parole?
Probation or Parole Officer's Name
Probation or Parole Officer's Phone
Do you owe any resitution? *    
If yes, how much?
Do you have fines, fees or community service hours?    
Do you owe any child support? *    
If yes, how much?

Substance Abuse History
What are your drugs of choice? *
What is the longest you have been clean/sober? *
In the last three years, I have abused...
(Check all that apply) *






When did you last use drugs/alcohol? *
Have you had substance abuse treatment before? *    
If yes, when?
Where?
Where were you most recently in treatment?
What dates?

Medical/Health History
Describe any medical problems you have *
500 character limit
Do you receive disability payments? *    
If yes, list the reason you receive them, the date they started and the amount
500 character limit
Have you ever been hospitalized
(for any reason other than pregnancy)? *		    
If yes, where, when and why?
500 character limit
Are you currently taking any medications? *    
If yes, please list the name, the reason you are taking it, and the dosage
500 character limit
Is there any reason that you are unable to work for 40 hours per week? *    

Mental Health History
Describe any mental health problems you have or have had in the past *
500 character limit
Are you currently being treated for a mental health issue? *    
If yes, what is it? Where and when did you begin being treated for it?
500 character limit
Where have you received help for your mental health problems?
Have you ever been diagnosed with any of the following
(Check all that apply) *



Have you ever been suicidal? *    
If yes, give details
(when, what happened, etc.)
500 character limit
Do you have a history of repeated relapse back into active addiction? *    
In treatment, did you learn about Twelve Steps (AA/NA) recovery? *    
Are you committed to a Twelve Step model of recovery? *    
Do you accept yourself as being an addict or alcoholic? *    
Are you willing to commit to our program for a minimum of 9 months? *    
Are you willing to take responsibility for your own actions? *    
Do you understand that the orientation period is at least 30 days? *    
If you have mental health issues, are you taking medications as prescribed? *    
Have you carefully read the Hawley House Program Overview? *    
By entering your initials here, you confirm that your answers are all accurate *
Email *
Comments
 
Enter the text you see here.
 
  * = required