Intake Form – Gilead House, Inc.

Name

First

Last

Gilead House is a female only facility, are you a biological female?

Yes
No

If no, please email us to see what other facilities might be available for you.

Date of Birth (Month/Day/Year)

(Month/Day/Year)

Point of Contact

If achieve? of

Your phone number? Or your point of contact?

Email (yours or your point of contact)

Are you currently un-housed?

Yes
No
I will be in the near future

Do you have Health Insurance

Yes
No

It is not required, we just like to know in advance.

If Yes, please provide Insurance details

Insurance Name, Member Numbers, etc.

Are you currently, or do you plan to be, a participant in the Recovery Works program?

Yes
No

If so, either contact your CJP or use the following link to submit a self-referral form. Once completed, you will enter the queue and one of the Howard County facilities will contact you. https://pacerecoveryworks.org/

Who is your Attorney or Probation Officer

If none, type N/A

If you have a pending court case, please list date and county.

Date of the court case and county where it will take place If none, type N/A.

What are the current or pending charges?

If none, type N/A.

If you have a Discharge Date, please share.

Include the date. If none, type N/A.

Have you ever been a resident or client at the Gilead House?

Yes
No

If YES, please tell us when

If none, type N/A.

Have you ever been diagnosed with a mental illness?

Yes
No

If you have been diagnosed with a mental health disorder, are you on any medications? Please list below.

List any medications. If none, type N/A.

Do you have any heath diagnosis and what medications are you currently taking?

Share health information and list medications. If none, type N/A.

Why do you want to come to the Gilead House? And what do you hope to achieve?

Please share any additional information that you feel would help us better understand your situation

How did you hear about the Gilead House?

OUR MISSION STATEMENT

GILEAD HOUSE, INC.