Mercer County Fellowship Home

421 Scott Street

Bluefield, WV 24701

   APPLICATION FOR CONSIDERATION AND/OR INTERVIEW FOR ADMISSIONS  

CURRENT DATE ___________________

LAST                                                                                                     M                FIRST                                                                                                       

ADDRESS                                                                                                                                                                                                                                  

PHONE  (          )             -                                    

DATE OF BIRTH          /         /                 AGE                            SEX                 

RESIDENT OF WV ?                      IF NOT, WHERE                                                                            MARITAL STATUS:                                          

SOCIAL SECURITY #:                     -            -                         EDUCATION COMPLETED:                                                                                     

EMPLOYMENT (CIRCLE ONE):  EMPLOYED      |     RETIRED     |    UNEMPLOYED    |    STUDENT    |    DISABLED 

IF EMPLOYED - WHERE                                                                                                                                    

VETERAN (Y/N)                                      WHAT BRANCH                                                                                                                                                     

D ISABLED (Y/N)    IF YES,  CIRCLE:   |    SSI    |  |    SOCIAL SECURITY     |   |     VA BENEFITS     |   |     WORKER S COMP     | 

WHAT ARE YOUR PRESENT LIVING ARRANGEMENTS                                                                                                 

EVER BEEN A RESIDENT OF MCFH BEFORE (Y/N)                   IF YES, DATES                                                                                    

EVER BEEN A RESIDENT OF ANY FELLOWSHIP HOME OR HALF-WAY HOUSE IN THE PAST (Y/N)                                                 

              IF YES - WHERE                                                                                                      HOW LONG:                                                               

HAVE YOU BEEN A RESIDENT/CLIENT OF A TREATMENT PROGRAM IN THE PAST (Y/N)                   

  IF YES - WHERE                                                                                             H OW  LONG                          

HAVE YOU BEEN IN A DETOX BEFORE                              NUMBER OF TIMES                 

HAVE YOU BEEN AN IN-PATIENT IN A PSYCHIATRIC FACILITY(Y/N)                                                                   

  HOW LONG                                                        WHERE                                                                                                                  

HAVE YOU BEEN HOSPITALIZED DUE TO DRINKING/DRUGS                                                                                                                        

SUBSTANCE OF CHOICE  (ALCOHOL OR DRUGS) ____________________________    LAST TIME USED ___________________________

CAN CLIENT PASS A DRUG/ALCOHOL SCREEN INCLUDING "THC"   (Y/N)__________________________________

LIST CURRENT MEDICATIONS ____________________________________________________________________________________

IS CLIENT [BIPOLAR] (Y/N) _________________         DOES THE CLIENT HAVE A [MENTAL ILLNESS] (Y/N)  _____________________

IS THE CLIENT AMBULATORY?  (ABLE TO CLIMB STEPS, DO HOUSE AND YARD CHORES) ______________________________

CLIENT CURRENTLY FACING LEGAL ISSUES (Y/N) ____________      ANY PAST DRUG FELONIES (Y/N)   _______________

CONTACT INFORMATION:

Director Jim Mcclanahan

Phone (304) 327 - 9876       Fax (304) 327 - 6234

email jimmcclanahan1@frontier.com