Resident Application | Dismas Home Of New Hampshire

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Dismas Home New Hampshire
Application for Residency

Please fill out this form as completely as you can.

Eligibility requirements:

Women who are or have been justice involved
18 to 60 years of age
No conviction of arson, sex offense, violent crime, or assault
No violent behavior while incarcerated
Income which falls below 400% of the Federal Poverty Level
Resident of New Hampshire

Name:

Date:

Date of Birth:

Age:

Insurance Provider:

Insurance ID:

Current Address:

Have you ever lived in Manchester

If you are or were on parole or probation,
what was or is your release date?

Who is your Parole or Probation Officer?

Address prior to incarceration:

County:

Marital Status:

Do you have any Children?

Yes No

If yes, are any under 18?

Yes No

Are any of your Children in your custody?

Yes No

How many boys:

How many girls:

Do you have Parental Rights?

Yes No

Are any of the children under temporary Guardianship?

Yes No

If yes, who has temporary guardianship of your children?

Do you have a spiritual preference?

Veteran Status

Were you a member of the Armed Forces?

Yes No

Was your discharge:

Employment History

Were you employed prior to incarceration?

Yes No

Employer and Address:

Start Date:

End Date:

Select your job type:

Position held:

Reason for Leaving:

Second Employer and Address:

Start Date:

End Date:

Select your job type:

Position held:

Reason for Leaving:

If unemployed before incarceration, what was your source of income?

Do you currently have a job?

Yes No

If yes, what is your current employer:

Supervisor:

Telephone:

If no, do you have any job leads, ideas and/or offers?

Yes No

If Yes, with whom?

Location:

Type of work:

What are your Skills?

Have you signed up for work through a job site like Indeed?

Yes No

Do you have a current resume?

Yes No

Length of sentence for most recent incarceration:

Release Status:

Have you been arrested before this most recent incarceration?

Yes No

Date Released

Have you been incarcerated before?

Yes No

Do you have any pending charges?

Yes No

Do you have a court date?

Yes No

Do you have a public defender or an Attorney?

Yes No

If yes, what is your defender/attorney's name and number?

For each Family Member previously or currently incarcerated; Please provide their name / date of / length / location / and offence

Have you ever been involved in gang activity?

Yes No

Have you ever been involved in prostitution?

Yes No

Please select all outstanding debts that apply:

Child support Court costs or fines Civil Judgements Tickets Back Mortgage Utility bills Supervision fees restitution loans

Please select any state assistance you think you are eligible for:

SSDI/SSI Food Stamps Medicaid Medicare

If yes, managing care provider:

Are you applying to any other programs?

Yes No

If yes, where?

Have you been accepted?

Yes No

Did you graduate from high school or get a GED?

Yes No

If no, last grade completed

If yes, name and location of High School

Year graduated

Vocational training (if applicable)

If applicable, name and location of College or Technical School

Year graduated

Degree or Vocational training:

Do you have a place to live now or after release? If yes, with whom?

Are you currently homeless?

Yes No

Please evaluate the Following:

How connected do you feel to your family?

Not at all Slightly Moderate Strong

How connected do you feel to your community?

Not at all Slightly Moderate Strong

Do you think of yourself as someone who contributes to the community?

Not at all Slightly Moderate Strong

How important to you is support from others?

Not at all Slightly Moderate Strong

How anxious are you about being out of prison?

Not at all Slightly Moderate Strong

Do you feel positive about the direction your life is taking?

Not at all Slightly Moderate Strong

Do you want to change your life, and why?

What is your primary source of emotional support upon release?

What are your clothing needs? do you have clothing stored somewhere, and if yes, where?

If accepted what are your goals?

Prior substance use disorder treatment:

Please list dates of treatment beginning with oldest and include:

Type of treatment (detox, IOP, 28-day, 90-day, Individualized)
Did you complete treatment?
If yes, how long were you sober after treatment?
If you relapsed, what was the trigger?

Are you currently substance free?

Yes No

How long have you been substance free?

How long have you been in recovery?

First drug of choice

Date of last use:

Second drug of choice

Date of last use:

Third drug of choice

Date of last use:

Are you in Drug Court?

Yes No

If yes, which Drug Court? Who is your is your counselor & email address?

Are you in pre-trial?

Yes No

If yes, where?

Eligibility Requirements

I attest that I meet the eligibility requirements as outlined:

Women who are or have been justice involved in a NH County or State
18 to 60 years of age
No conviction of arson, sex offense, or violent crime or assault
No violent behavior while incarcerated
Income which falls below 400% of the Federal Poverty Level
Resident of New Hampshire

Medication Assisted Treatment

If I am recieving Medication assisted treatment for addiction; I attest that I am being treated with:

Sublocade, Vivitrol, Naltrexone monthly injections OR
Zubsolv, Suboxone, or Buprenorphine in the form of sublingual films or tablet form OR
Methadone doses which can be administered at Dismas Home of New Hampshire under staff supervision

Please sign by entering your name here:

Date:

Name of Person, Title, or Organization

Address (Street, City or Town, and Zip Code)

Your Name

Date of Birth:

Telephone Number

Information to be disclosed

Assessment Diagnosis Substance Abuse Evaluation Medical Information Psychological Evaluation Psychiatric Evaluation Treatment Plan/Summary Medication & Management of Medication Education Information Toxicological Reports/Drug Screens Other

If other, please list additional information to be disclosed.

PURPOSE: The purpose of this disclosure of information is to improve assessment and transition planning, share information relevant to treatment when appropriate and coordinate transition of services.

REVOCATION: I understand I have the right to revoke this authorization, in writing, at any time by sending written notification to DismasvHome of New Hampshire at 102 Fourth Street, Manchester, NH 03102. I further understand revocation of the authorization is not effective to the extent that action has been taken in reliance on the authorization.

EXPIRATION: Unless sooner revoked, this authorization will expire one year from the date it is signed.

CONDITIONS: I further understand Dismas Home of New Hampshire will not condition my acceptance and services on whether I give authorization for the requested disclosure. However, it has been explained that failure to sign this authorization may have the following consequences of not being able to provide services.

FORM OF DISCLOSURE: Unless you have specifically requested in writing that the disclosure be made in a certain format, we reserve the right to disclose information as permitted in any manner we deem appropriate and consistent with applicable law, including but not limited to verbally, paper format or electronically.

REDISCLOSURE: I understand that there is the potential that protected health information disclosed pursuant to this authorization may be re-disclosed by the recipient and the protected health information will no longer be protected by the HIPAA Privacy Regulations unless a State Law applied is more strict than HIPAA and provides additional privacy protections. Federal Law prohibits the person or organization to whom disclosure is made from making any further disclosure of substance abuse treatment information unless further disclosure is expressly permitted by the written authorization of the person to whom it pertains or otherwise permitted by 42 CFR Part 2.

Please sign by entering your name here:

Date:

If you are signing as a personal representative of an individual, please describe your authority to act for this individual (power of attorney, healthcare surrogate, etc).

Check this box if applicant refuses to sign authorization.

Witness to Signature:

Date:

For questions regarding the application or release of information, please call Dismas Home of
New Hampshire Main Office at (603) 782 3004

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603-782-3004
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Manchester, NH 03102

The preparation of this (report, document, etc.) was financed under a Contract with the State of New Hampshire, Department of Health and Human Services, with funds provided in part by the State of New Hampshire and/or such other funding sources as were available or required, e.g. the United States Department of Health and Human Services.

The Department of Health and Human Services’ Mission is to join communities and families in providing opportunities for citizens to achieve health and independence.

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