LightHouse Women's Residence Program Application
This file is an application form for the Lighthouse Women's Residence Program. It includes sections for referral information, client information, children's details, diagnosis, and treatment history. All information must be completed by a referring party before being considered for admission.
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How do I fill this out?
To fill out the Lighthouse Women's Residence Program Application, gather all necessary information about the client and their children. Ensure that you have details about any prior psychiatric and chemical dependency treatments. The form must be completed by a referring party and not by the client themselves.
How to fill out the LightHouse Women's Residence Program Application?
1
Gather personal and contact information of the client.
2
Collect details about the client's children, including names and ages.
3
Record current and past diagnoses of the client.
4
Document the client's prior psychiatric and chemical dependency treatment history.
5
Submit the completed form to the appropriate address or contact.
Who needs the LightHouse Women's Residence Program Application?
1
Referral agencies need this form to provide accurate information about their clients.
2
Healthcare professionals use this form to gather detailed histories of their patients.
3
Clients in need of residential care at the Lighthouse Women's Residence require this form for admission.
4
Social workers need this form to assist their clients in accessing proper care.
5
Counselors use this form to evaluate the treatment history and current needs of their clients.
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What are the instructions for submitting this form?
To submit this form, ensure that all sections are fully completed. You can email the completed form to admissions@lighthouse.org or fax it to (716) 831-8666. Alternatively, you may mail it to 244 Hempstead Avenue, Buffalo, New York 14215. Ensure that all information is accurate to avoid delays in processing. For additional assistance, contact (716) 831-7877.
What are the important dates for this form in 2024 and 2025?
Ensure that all sections of the form are completed before submission dates in 2024 and 2025.
What is the purpose of this form?
The purpose of the Lighthouse Women's Residence Program Application is to gather comprehensive information about the client seeking admission to the program. This includes details about their personal information, treatment history, and family situation. The collected information will be used to evaluate the client’s eligibility and to plan the appropriate care.
Tell me about this form and its components and fields line-by-line.
- 1. Referral Information: Includes details about the referring party and their contact information.
- 2. Client Information: Collects personal information about the client, such as name, address, phone numbers, and social security number.
- 3. Children's Details: Gathers information about the client’s children, including names and ages, and their current custody status.
- 4. Diagnosis: Records current DSM-TR diagnostic impressions and discharge dates if applicable.
- 5. Treatment History: Documents prior psychiatric and chemical dependency treatments, both inpatient and outpatient.
What happens if I fail to submit this form?
Failure to submit this form may result in delays or ineligibility for admission to the Lighthouse Women's Residence Program.
- Delayed Admission: Incomplete forms will not be processed, causing admission delays.
- Ineligibility: Failure to provide required information can result in ineligibility for the program.
How do I know when to use this form?
- 1. Referral Agencies: When referring clients to the residence program.
- 2. Healthcare Professionals: To document detailed histories of patients seeking residential care.
- 3. Clients Seeking Admission: As part of the application process for residential care.
- 4. Social Workers: To assist clients in accessing the Lighthouse Women's Residence.
- 5. Counselors: To evaluate and document treatment histories of clients.
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