Riverside Reentry 2.0 Application

Member's Information

Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Email address*

Home Phone

Cell Phone

Date of birth*

Place of birth*

Primary Language

Second Language

Driver's License Number*

Social Security Number*

Disability*

Yes
No

Do you require any accommodations?*

Yes
No

If yes, please explain:

Physical Description

Height*

Weight*

Race*

Eye color*

Hair color*

Sex*

Male
Female

Body marks / Tattoos / Piercings

Emergency Contact Information

Primary Name*

First Last

Relationship*

Home Phone

Cell Phone

Address*

Street Address City State ZIP Code

Medical History

Legal / Criminal Information

Current conviction

Sentence

Referring agency

Do you have any pending criminal or civil charges?*

Yes
No

If yes, please explain

Allergies

Spiritual History

Religious affiliation*

Active or inactive?*

Active
Inactive

Do you attend a local church?*

Yes
No

If yes, name of church

How significant is religion to your everyday life?*

Occupational / Educational Information

Employer

Occupation

Hourly wage

How long have you been employed with this company?

Work

Part time
Full time

If currently a student: What school?

Field of study

Part-time/Full-time

Part time
Full time

Choose last year of school completed*

Other

Any job-related certifications?

Are you interested in obtaining a certificate in another area? If yes, what kind of certificate?

Military service (including branch of service and dates)

Reasons for Visiting the Day Reporting Center

What issues or concerns have led you to the Day Report Center?*

What concerns have led you to pursue counseling?*

Where is this impacting you the most? Choose all that apply:*

When did this begin to be a problem for you?*

Please rate the severity of your present concerns*

Mild
Moderate
Severe

What do you hope to gain from counseling?*

If other people are involved in your present problem, who are they and how could they help improve the situation?

Please check services needed

Case Management
Employment
Job Training
Government Assistance Application
Medical Referral / Dental Referral Documents
Counseling: Mental Health
Counseling: Substance Abuse
Counseling: Family
Counseling: Spiritual

Agreement and Authorization Signature

I believe that the statements I have made are true and correct. I hereby authorize Riverside House 2.0 to conduct any background checks, as needed; as well, as to contact, communicate, and verify any references or names listed on this application. I understand that any discrepancy or lack of information may result in the rejection of this application.

Signature of Applicant (Type name to sign)*

Date*

Appointments

All appointments are made through the administrative Assistant staff. Most appointments can be scheduled Monday - Friday from 10:00 am to 5:00 pm., Appointments should be cancelled 24 hours prior to the scheduled appointment time to allow another client to be contacted to fill your appointment time. Since a specific block of time is set aside for you, Rentry 2.0 appreciates your every effort to keep your scheduled appointment.

Initial*