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ADMISSIONS

Application/Screening Form

Applications are processed daily by Greenhope’s intake department. A response is generated via email or telephone contact within 24 hours of receipt of an application. For questions regarding the application form or a form that was recently submitted, contact Estelle Pierce, Legal Services Director at (212) 996-8633 or email epierce@greenhope.org.

Complete the screening form below. Failing to thoroughly complete the screening form may delay the application process.

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(Check all that apply)

Program:
Residential/Inpatient

Outpatient

Day Treatment

Criminal Status:
Parole

Probation

No Criminal Status


Open Criminal Case/ATI

Open Family Case

Other  

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First Name:

Last Name:

Age:

DOB:

month  day  year

(Example: 04 21 1976)

Last Known Address:





Social Security #:

 

(Example: 123 45 6789)

NYSID #:

Location:

Telephone:

Street Address:

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Current/Past Psychiatric Status:

Suicidal:

Yes No

When

How

Why

Current Medical Concerns:

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Current Legal Status/Charge:

Time Facing

Time Maxed

Probation/Parole Officer:

Name

Telephone Number

Email


Attorney:

Name

Telephone Number

Email


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Current/Past Chemical Dependence Hx:

Last Grade Completed:

Associate Degree
Bachelors Degree
Masters Degree
Other
If other, please detail:
Some College
# of Years:

Income Status:

Release Date:

month  day  year

(Example: 04 21 1976)

Appointment Date:

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Employed:

Yes No

Number of Children:

Whereabouts:
family/friend

foster/kinship care

Case Worker:

Name

Telephone Number

Email


Referral Source:

Date of Application:


(Example: 04 21 1976)

Comment: add any other pertinent data

 
   

 

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