Apply for IOP House CONFIDENTIAL APPLICATIONApplication FormComplete each step to submit your confidential application.Private applicationPreparing secure submission...This form requires JavaScript. Please contact the provider for another application option.Personal detailsFirst Name *0 / 250Last Name *0 / 250DOB *SS#0 / 250Gender *MaleFemaleNon-binaryAgenderMy gender is not listedPrefer not to answerEthnicityAmerican Indian or Alaska NativeAsianBlack or African AmericanHispanic or LatinoNative Hawaiian or Other Pacific IslanderWhiteDo you have a Physical ID/Driver's Licence?YesNoDo You Drive *YesNoAre You Currently Homeless *YesNoCell Phone *0 / 10Email *Employment detailsAble To Work *YesNoIF NO, EXPLAIN *0 / 250Employment Status *Not currently employedCurrently EmployedOn workers compensationDisabledIf employed: Company Name0 / 250Tell us about yourself and where you are coming from:0 / 250Emergency Contact0 / 10Recovery historyHave You Ever Worked A Step Based Program? *YesNoHave You Lived In A Recovery House Before? Y Or NYesNoIf Yes, Name It0 / 250Have you previously been part of this program?YesNoSubstance(s) Used In The Past0 / 250Drug Of Choice0 / 250Other Drugs/alcohol Used In Last 6 Months0 / 250When Did You Last Use0 / 250Health & medical detailsAre you currently on any medications? If so list them along with dosages0 / 250Please list all food and medication allergies0 / 250Any other medical conditions for us to be aware of?0 / 250Do you currently have health insurance?YesNoIf yes, what insurance company?0 / 250Insurance Member ID:0 / 250Legal history & signatureSuicide AttemptsYesNoTimes0 / 250Felony(S)YesNoFor0 / 250On ParoleYesNoFor0 / 250On ProbationYesNoFor0 / 250PO Name And Number0 / 250Any Pending Charges?YesNoDo You Have Any Charges Of Assault On Record?YesNoReg. Sex OffenderYesNoDUI (DWI)YesNoApplicant’s Name Printed0 / 250DateBy clicking 'Submit', you agree to Empowering Communities with Compassionate Mental Health Care Privacy Policy. You consent to receive phone calls and SMS messages from Empowering Communities with Compassionate Mental Health Care to provide updates on our services. Message frequency depends on your activity. Message and data rates may apply. You may opt out at any time by texting 'STOP' or text 'HELP' for more information.Review & submitCheck every answer before submitting. Use Previous to make changes.Review and approval *I have reviewed my application and confirm that the information provided is accurate to the best of my knowledge. I approve submitting this application. Read the privacy notice.Submit applicationPlease do not fill in this field.
