Adult Treatment Application Form Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Please complete the entire application. Fields with asterisks* including associated fields are required in order to submit your application for review. Review times vary depending on the complexity of the application. Make sure you have applicant’s identification available to upload (Mandatory) Section 1: DEMOGRAPHICSAre you completing this application for someone else? *Choose oneYesNoIf you replied yes, you will need to upload: Power of Attorney or; Signed Consent by the client allowing you to complete this application and; A form of identification from the client. You may find the consent on our website under the forms tab under Adult Service. Date of Application *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Full Name *FirstMiddleLastSocial Security Number *XXX-XX-XXXXAddress (current or last known residence) *Address Line 1CityState / Province / RegionPostal CodeAre you currently Homeless? *Choose OneNoYesIf yes, last known living arrangements *Date of Birth *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920XX-XX-XXXXPhoneEmailSex *Choose OneMaleFemaleTransgenderOtherPrefer not to sayIf other, please specify *Marital Status *Choose OneMarriedSingleDivorsedWidowedDo you have children? *Choose OneYesNoIf yes, how many? *Ethnicity *Choose oneAfrican AmericanAlaskan NativeAmerican IndianAsianFilipinoHispanicNative HawaiianPart HawaiianOtherPacific IslanderUnknownWhat service are you applying for? *Choose oneResidentialOutpatient KaneheOutpatient WaipahuNextSection 2: REFERRAL SOURCEWho is referring you? *Choose OneMyselfProbationParolePre Trial OfficerAttorney/PDC.A.R.E.S.CPSCase ManagerAMHD Case ManagerOutside Treating ProviderMy Physician MDMy PsychiatristMay we contact your referral source? *YesNoReferral's Name *FirstLastPhone *Agency/Organization *By answering yes, you give us permission to contact your referral source. The purpose of the disclosures authorized in this consent is for: Consultation on behalf of the client’s substance abuse/mental health treatment related to the treating condition. I understand that my substance abuse disorder and treatment records are protected under the Federal regulations governing Confidentiality and Drug Abuse Patient Records, 42 C.F.R. Part 2, and the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 45 C.F.R Part 160 & 164, and cannot be disclosed without my written consent unless otherwise provided for by the regulations. I also understand that I may revoke this consent in writing at any time except to the extent that action has been in reliance on it, and that in any event this consent expires automatically as follows: NextSection 3: SUBSTANCE ABUSE INFORMATIONYou must complete this section in order to qualify for treatment services. Answer all the questions as accurately as possible. Choose what applies in the dropdown menu. Substances Used *Choose oneAlcoholCocaineMarijuana/Hashish/THCHeroinNon-Rx MethadoneOther Opioids/SyntheticsPCPOther HallucinogensMethamphetaminesOther AmphetaminesOther StimulantsBenzodiazepineOther Non-Benzodiazepine TrnquilizersBarbituratesOther Barbiturates Sedative/HypnoticsInhalantsOver-The-CounterOtherCocaineCrackOther Stimulant DependenceRoute of Administration *Choose oneOral (by mouth)SmokingInhalationIntravenousHow Often? *Choose oneDaily3-6 Times/week1-2 Times/week1-3 Times in past 30 daysNone in past 30 daysDate of Last Use *Substances Used Choose oneNoneAlcoholCocaineMarijuana/Hashish/THCHeroinNon-Rx MethadoneOther Opioids/SyntheticsPCPOther HallucinogensMethamphetaminesOther AmphetaminesOther StimulantsBenzodiazepineOther Non-Benzodiazepine TrnquilizersBarbituratesOther Barbiturates Sedative/HypnoticsInhalantsOver-The-CounterOtherCocaineCrackOther Stimulant DependenceRoute of AdministrationChoose oneOral (by mouth)SmokingInhalationIntravenousHow Often?Choose oneDaily3-6 Times/week1-2 Times/week1-3 Times in past 30 daysNone in past 30 daysDate of Last Use Substances Used Choose oneNoneAlcoholCocaineMarijuana/Hashish/THCHeroinNon-Rx MethadoneOther Opioids/SyntheticsPCPOther HallucinogensMethamphetaminesOther AmphetaminesOther StimulantsBenzodiazepineOther Non-Benzodiazepine TrnquilizersBarbituratesOther Barbiturates Sedative/HypnoticsInhalantsOver-The-CounterOtherCocaineCrackOther Stimulant DependenceRoute of AdministrationChoose oneOral (by mouth)SmokingInhalationIntravenousHow Often?Choose oneDaily3-6 Times/week1-2 Times/week1-3 Times in past 30 daysNone in past 30 daysDate of Last UseNextPlease list any other information about your substance abuse that you would like us to know. Please choose an answer for all the questions as accurately as possible. Choose what applies in the dropdown menu. Experience any complications from using or drinking? *Choose oneNoYesNot SurePlease explain? *Have you given up important activities because of your using or drinking? *Choose oneNoYesNot SurePlease explain? *Have you ever blacked out or overdosed? *Choose oneNoYesWhen and how often? *Spend a lot of time using or drinking or recovering from using or drinking? *Choose oneNoYesNot SurePlease explain? *Did you know that using and/or drinking is causing problems for you? *Choose oneNoYesNot SurePlease explain? *Experienced withdrawals or needed detox? *Choose oneNoYesWhen and where? *Do you vape or smoke cigarettes? *Choose oneNoYesIf yes, are you interested in quitting? *Choose oneNoYesWould you like to see someone about quitting? *YesNoHave you received treatment before? *Choose oneNoYesIf yes, please describe below. *Section 4: MEDICAL/PSYCHIATRIC INFORMATIONPlease complete this section as accurately as possible. Include all the information necessary so our medical team can complete their review. Missing information may delay your application review process. You may upload needed documents in this section as necessary. Do you have a medical condition we need to know about? If yes, please have all the information available to answer the next series of questions or you will not be able to proceed further *yesNoMedical Condition *How Long? *Treating Physician *List Medication *Medical Condition How Long? Treating Physician List Medication Medical Condition How Long? Treating Physician List Medication Please list additional psychiatric information below like, are you taking your medication regularly? do you consider yourself stable? or any other information that would be helpful to treating you?Do you have a psychiatric or mental health condition we need to know about? If yes, please have all the information available to answer the next series of questions or you will not be able to proceed further *yesNoPsych Condition *How Long? *Treating Physician *List Medication Psych Condition How Long? Treating Physician List Medication Psych Condition How Long? Treating Physician List Medication Please list additional psychiatric information below like, are you taking your medication regularly? do you consider yourself stable? or any other information that would be helpful to treating you? *NextDo you have a history of seizures? *Choose oneNoYesIf yes, please explain *Have you ever attempted suicide? *Choose oneNoYesIf yes, please explain *Do you feel suicidal now? *Choose oneNoYesIf yes, please explain *Any communicable diseases? *Choose oneNoYesIf yes, please explain *Do you feel like harming anyone else? *Choose oneNoYesIf yes, please explain *Do you feel like harming yourself? *Choose oneNoYesIf yes, please explain *NextDepartment of Health requires a current physical and TB test for all residential admission. Date of Last Physical?MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Any known Allergies? *Choose oneNoYesif yes, please list *Date of Last TB TestMM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Vision problems? *Choose oneNoYesDo you wear/need glasses? *Choose oneNoyesDate of Last MMRMM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Hearing Problems? *Choose oneNoYesDo you need help with this? *Choose oneNoYes**Please upload documents here** (Identification mandatory to apply. Physicals, TB test, psyh. evals, etc.) *Treating Physician/PsychiatristDoctor's Phone NumberMay we contact your doctor? *YesNoNot applicableMedical Insurance *Choose oneNoneHMSA QuestAloha CareUHCCOhanaOhana CCSUHAKaiserMedical Plan NumberMay we contact your medical insurance provider? *YesNoNot applicableBy answering yes, you give us permission to contact your referral source. The purpose of the disclosures authorized in this consent is for: Consultation on behalf of the client’s substance abuse/mental health treatment related to the treating condition. I understand that my substance abuse disorder and treatment records are protected under the Federal regulations governing Confidentiality and Drug Abuse Patient Records, 42 C.F.R. Part 2, and the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 45 C.F.R Part 160 & 164, and cannot be disclosed without my written consent unless otherwise provided for by the regulations. I also understand that I may revoke this consent in writing at any time except to the extent that action has been in reliance on it, and that in any event this consent expires automatically as follows: LEGAL INFORMATIONNote: Please review Section 1: Referral Source for Legal Representation (if any) and consent to contact. Legal Representative's NameEmail AddressPhone NumberHave you been convicted of a crime that was violent in nature? *Choose oneNoYesIf yes, please list crime and when *Any pending charges? *Choose oneNoYesIf yes, please list charges and when *Ever attended anger management/domestic violence classes or sessions? *Choose oneNoYesIf yes, Did you complete the classes/sessions? *Choose oneNoYesIf no, please explain? *Are you currently incarcerated? *YesNoIf yes, where? *Have you experienced long terms of incarceration lasting more than a year? *Choose oneNoYesIf yes, please explain *Any pending court dates? *Choose oneNoYesIf yes, please dates and for what *IMPORTANT PLEASE READ: Hina Mauka uses various resource services to check the legal and/or criminal status of the justice involved persons. The information is used to determine if an applicant is eligible and appropriate for services here at Hina Mauka. This information is kept confidential and is used only for this sole purpose. Your permission to Consent?Choose oneYesNoNot applicableBy answering yes, you give us permission to contact your referral source. The purpose of the disclosures authorized in this consent is for: Consultation on behalf of the client’s substance abuse/mental health treatment related to the treating condition. I understand that my substance abuse disorder and treatment records are protected under the Federal regulations governing Confidentiality and Drug Abuse Patient Records, 42 C.F.R. Part 2, and the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 45 C.F.R Parts 160 & 164, and cannot be disclosed without my written consent unless otherwise provided for by the regulations. I also understand that I may revoke this consent in writing at any time except to the extent that action has been in reliance on it, and that in any event this consent expires automatically as follows: By signing below I acknowledge that the information provided in this form to be accurate and true. I also understand by signing below that any part of the information provided to be inaccurate or the lack there of may cause a delay in the application review process. Name *FirstLastPatient/Carer/Guardian Signature * Clear Signature Paragraph TextParagraph TextParagraph TextSubmit Application
