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

Veteran Status

Employment History

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?

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.

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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