EmailMeForm
Khloe Lynn's Application
Name
First
Last
Birth Date
MM
/
DD
/
YYYY
Phone
Gender
Please select
Female
Email:
Current Address and Living Arrangements:
Referred by: Name, Relationship, Phone, Email. Please be sure to provide best contact information to reach you to conduct future phone interview: (Case Workers/Clinicians contact number, extension, email, etc.)
Source of Income: Employer, Hours per week, Income, Benefits
Substance Use: Substances, Route, Frequency, Last use
Do you attend Recovery Meetings? AA, NA, SMART, Refuge, etc.
Yes
No
Do you have Health Insurance?
Yes
No
Past attendance of PHP/IOP?
Yes
No
Are you interested in PHP/IOP Services?
Yes
No
Medical History
Known allergies:
Yes
No
To what?
Current Medications (include MAT):
Currently Pregnant:
Yes
No
Unknown
Legal History
Current Probation: Court House, PO Name, PO Contact:
Have you ever been convicted of a crime or received probation?
Yes
No
Currently any active Restraining Orders:
Yes
No
Description of Restraining Order; If Applicable:
Have you ever been convicted of a sex crime, arson or registered as a sex offender?
Yes
No
Active DCF involvement:
Yes
No
What is your marital status?
Never married
Married
Divorced
Separated
Widowed
Partnered/significant other
Highest level of education:
Some Schooling
Some High School
High School Diploma/GED
Some College
College Degree
Please list your goals for (1) month, (3) months and (1) year from now:
Are you currently working?
Yes
No
Are you
Retired
Disabled
Laid off
Sick leave
Do you receive SSI/SSDI?
Yes
No
Specify Disability:
Which location are you interested in?:
Millbury, MA.
Auburn, MA.
Move in date requested:
Authorization for release of information
I hereby authorize Khloe Lynn's and its designated agents and representatives to conduct a comprehensive review of my background. I understand that the scope of this background check may include, but is not limited to the following areas: verification of social security number; credit reports, current and previous residences; employment history, education background, character references; drug testing, medical records from a treatment facility, civil and criminal history records from any criminal justice agency in any or all federal, state, county jurisdictions; driving records, birth records, and any other public records. I further authorize any individual, company, firm, corporation, or public agency to divulge any and all information, verbal or written, pertaining to me, to Tricord Properties or its agents.
Authorization of terms:
Agree to terms
Do not agree
