NOTE
Cynthia Day Family Center (CDFC) program is offered for pregnant women and mother with children (no more than two children, from under 12
yo). Commitment time is 6 months. Pregnant clients could stay until after the baby is a year old.
Page 1 of 5
Cynthia Day Family Center Application
DEMOGRAPHICS
Date of Application: ______________________
Name: ___________________________________________________________
Age: _________ Date of Birth: ______________________
Last (4) digits of SSN: __________________
Phone: _____________________________________________________
Can we leave a message at this number? __________
Current living situation: Community ______ Homeless ______ Shelter ______ Incarcerated ______ Treatment Center _______
Current Street Address: ___________________________________________City: _________________________ State: _______ Zip Code: _______________
Length of time at current location: _____________________________________________________________
If incarcerated, please state when are you eligible for release or parole? ___________________________________________________________
How did you hear about our program? _________________________________________________________________________________________________
Have you applied here before? (YES or NO) ________ If YES; when ___________________________________
Do you have a NH Picture ID? YES______ NO_______ (required for admission)
Current Relationship Status: Single Married
Divorced Widowed Other: ____________________
Children: Y / N
How Many? _________
Custody? __________________________________________________________
Health Insurance information ____________________________Insurance number___________________________
Are you the primary carrier of this insurance? YES NO Primary carrier of the insurance._______________________________________
Are you pregnant? _____YES
_____NO
_____ Unknown
Anticipated due date: __________________________
Are you currently receiving prenatal care? ___________ If YES, Where? ___________________________________________
Are you currently using substances of choice? ______ YES ______ NO
If yes, please list type and frequency of substance (s) ____________________________________________________________________________________
Current Length of Sobriety: _________________________________ Is English your first language? __________
How would you describe your race/ethnicity?: ________________________________ Religious Affiliation: __________________________________
EMERGENCY CONTACT INFORMATION
1. Name: ______________________________________________________________
Relationship: ______________________________________ Phone: ________________________________
Level of support (available and close by, distant, etc…) ______________________________________
Can this person be contacted in the event of admission to program? Y/N (please circle)
SUBSTANCE USE
Have you ever been treated for alcohol/drug use? NO______ YES______ When/Where:
DATE (S) _________________________ LOCATION __________________________________________
DATE (S) _________________________ LOCATION __________________________________________
DATE (S) _________________________ LOCATION __________________________________________
DATE (S) _________________________ LOCATION __________________________________________
FAMILY-CENTERED
GENDER-SPECIFIC
HOLISTIC
INDIVIDUALIZED
615 Amherst Street * Nashua, NH 03063 * (603) 881-4848 * Fax (603) 598-3644 * www.keystonehall.org
Rev. on 3/15
Cynthia Day Family Center Application
Page 2 of 5
Have you ever completed a 28 Day program? NO_______ YES_______
When/Where: _____________________
_____________________________________________________________________
Are you on Methadone Maintenance or Suboxone/Subutex? __________ If YES, current dose: ________________
Provider Information: _________________________________ How long have you been on your maintenance program? ___________________
Drug of Choice
#1 ____________________
Date last used: ________________ How much did you use? _______________
How often do you use this drug? ____________________ Age of first use: ___________
How do you use it? (Circle all that apply) Smoke Snort/Inhale Inject
Oral Other: ____________
#2 ____________________
Date last used: ________________ How much did you use? _______________
How often do you use this drug? ____________________ Age of first use: ___________
How do you use it? (Circle all that apply) Smoke Snort/Inhale Inject Oral Other: ______________
#3 ____________________
Date last used: ________________ How much did you use? _______________
How often do you use this drug? ____________________ Age of first use: ___________
How do you use it? (Circle all that apply) Smoke Snort/Inhale Inject Oral Other: _____________
MEDICAL
Please list any medical conditions (Asthma, Diabetes, Hepatitis, HPV):____________________________________________________________
___________________________________________________________________________________________________________________________________________
Allergies (please include food, seasonal, and/or medicine related): ______________________________________________________________
___________________________________________________________________________________________________________________________________________
If you have any allergies or other medical conditions, do you carry any of the following with you (circle if applicable):
EPI pen
Inhaler
Other medication (insulin, etc.) Specify: ______________________________
Physician Name: ________________________________________________ Phone number: ________________________________
Address: _______________________________________________________________________________
Date Last Seen: ______________ Reason: ______________________ Date of last physical: ____________
Do you have any vision problems: (Y/N) ___________ Glasses/Contacts: (Y / N) ___________
Do you have any hearing problems: (Y/N) __________ Do you have any dental problems: (Y/N) _________
Have you ever experienced a concussion, or Traumatic Brain Injury (TBI)? NO _________ YES _________
(Please include accidents or combat related head injury) If yes, please list age of each injury and circumstances:
___________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________
Have you ever lost consciousness? ______ If YES, was consciousness lost for 30 minutes or more? ________
Circumstances:
_________________________________________________________________________________________________________________________________________________
FAMILY-CENTERED
GENDER-SPECIFIC
HOLISTIC
INDIVIDUALIZED
615 Amherst Street * Nashua, NH 03063 * (603) 881-4848 * Fax (603) 598-3644 * www.keystonehall.org
Rev. on 3/15
Cynthia Day Family Center Application
Page 3 of 5
Medications and/or vitamins currently taking (please list over the counter (OTC) and prescriptions): LIST SEPERATELY
NAME
DOSE
REASON FOR TAKING
Prescribing Physician
_________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________
All medication orders will be required upon Intake.
MENTAL HEALTH
Have you ever had any mental health care? Circle one:
current
past
never
Name of Counselor/Location: ______________________________________________________________________________________________________________
Have you been previously given any mental health diagnoses? ______ If YES, please list: ______________________________________________
_________________________________________________________________________________________________________________________________________________
Have you ever been hospitalized for mental health issues/concerns? ________ If YES, please list dates and circumstances:
_________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________
LEGAL
Have you ever been arrested (Y/N) _________ If YES, please explain offense/charges and provide dates:
OFFENSE/CHARGE
DATE
______________________________________________________________________________
_____________________________
______________________________________________________________________________
_____________________________
______________________________________________________________________________
_____________________________
Have you ever been convicted of arson? Y/N _________
Sexual Assault: Y/N
Violent Crime: Y/N
Have you ever been arrested, charged, or convicted of a sex offense? Y/N _______ If YES, please explain: ____________________________
__________________________________________________________________________ Are you a Registered Sex Offender? (Y/N) ________________
Are you currently on Parole or Probation (Y/N): ________ If YES, Name of Officer: __________________________________
District Office: _______________________________________ Phone: ______________________________
Any there any current restraining orders against you OR placed by you? ________
If yes, please explain: _______________________________________________________________________________________________________________________
________________________________________________________________________________________
Have you ever been charged with abuse and/or neglect of a child? __________________________________
Do you have any outstanding warrant against you? YES _________ NO ________
If answer YES, please specify the state(s) _________________________________________________________
EDUCATION/ VOCATION
Highest level of education/years completed: _________________________________________
Learning/Reading/Developmental Disabilities that may impact treatment? _____________________________
Are you currently enrolled in an educational program? ____________________________________________
If YES, where and what course of study: ________________________________________________________
FAMILY-CENTERED
GENDER-SPECIFIC
HOLISTIC
INDIVIDUALIZED
615 Amherst Street * Nashua, NH 03063 * (603) 881-4848 * Fax (603) 598-3644 * www.keystonehall.org
Rev. on 3/15
Cynthia Day Family Center Application
Page 4 of 5
Employer: ________________________________________ Occupation: _____________________________
Are you a veteran? (Y / N) _______________________ Years of active service in military: ________________
Children Currently Living with You (list additional children on back side)
1. Name:________________________________________________________ Male/Female:_________ DOB:_______________ Age: ___________
Age of Child: __________ Child SS#:__________________________ Current School/ Day Care Name: __________________________________________
Child’s Pediatrician: __________________________ Address: __________________________________
Name of Child’s Other Parent: ____________________________________________ Level of Involvement: _______________________________________
DCYF Involvement: (YES or NO) __________ If YES, Name of CPSW: _________________________________________________
District Office: ______________________________ CPSW Phone: _______________________________
Do you receive child support for this child? Yes______ Amount: $_________/mo. No_____ Pending _____
2. Name:________________________________________________________ Male/Female:_________ DOB:_______________ Age: ___________
Age of Child: __________ Child SS#:__________________________ Current School/ Day Care Name: __________________________________________
Child’s Pediatrician: __________________________ Address: __________________________________
Name of Child’s Other Parent: ____________________________________________ Level of Involvement: _______________________________________
DCYF Involvement: (YES or NO)__________ If YES, Name of CPSW: _________________________________________________
District Office: ______________________________ CPSW Phone: _______________________________
Do you receive child support for this child? Yes______ Amount: $_________/mo. No_____ Pending _____
CHILDREN-CURRENTLY NOT LIVING WITH YOU (list additional children on back side)
1. Name:______________________________________________________ Male/Female:_________ DOB:________________ Age: _____________
Address:____________________________________________________________________________________
Child’s Guardian: _____________________________________ Relationship to Child: _______________________________
DCYF Involvement (YES / NO) ____________ If YES, Name of CPSW: ___________________________________
District Office: ______________________________ CPSW Phone: ____________________________________
Your Level of Involvement/Contact with child: ____________________ Are you in the Process of Redeeming Guardianship? ____________
2. Name:_______________________________________________________ Male/Female:_________ DOB:________________ Age: _____________
Address:____________________________________________________________________________________
Child’s Guardian: _____________________________________ Relationship to Child: _______________________________
DCYF Involvement (YES / NO) ____________ If YES, Name of CPSW: ___________________________________
District Office: ______________________________ CPSW Phone: ____________________________________
Your Level of Involvement/Contact with child: ____________________ Are you in the Process of Redeeming Guardianship? ____________
FINANCIAL
If currently employed, please list the following:
Employer:
____________________________________
Hourly wages: $___________
Average hours per week: _________________hrs/wk
Do you currently receive WIC? __________________________
Do you currently receive Childcare Assistance from the State? ___________________ Step # ___________
Do you currently receive Public Assistance? YES_________ NO________ (If YES, please list):
TANF_________________
Date Started _____________ Monthly Amount $______________
Food Stamps ___________
Date Started_____________
Monthly Amount $______________
SSI____________________
Date Started_____________
Monthly Amount $______________
Unemployment__________
Date Started_____________
Monthly Amount $______________
FAMILY-CENTERED
GENDER-SPECIFIC
HOLISTIC
INDIVIDUALIZED
615 Amherst Street * Nashua, NH 03063 * (603) 881-4848 * Fax (603) 598-3644 * www.keystonehall.org
Rev. on 3/15
Cynthia Day Family Center Application
Page 5 of 5
City Welfare____________
Date Started_____________
Monthly Amount $______________
Other___________________
Date Started______________ Monthly Amount $______________
MONTHLY INCOME (approximate): ________________
Do you have MEDICAID Health Insurance? _____________ Medicaid # _____________________________
Please be aware that the Cynthia Day Family Center is not responsible for personal property or any money
brought into the facility.
PERSONAL REFLECTION (In your own words): Please share with us what goals you hope to attain while a participant in
Keystone Hall program?
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My signature certifies that, to the best of my knowledge, all of the above information is accurate.
I understand that releases may be requested for the purpose of contacting any of the above mentioned individuals.
______________________________________________
Applicant’s Signature
________________________
Date
FAMILY-CENTERED
GENDER-SPECIFIC
HOLISTIC
INDIVIDUALIZED
615 Amherst Street * Nashua, NH 03063 * (603) 881-4848 * Fax (603) 598-3644 * www.keystonehall.org
Rev. on 3/15