San Antonio
Urban Ministries
Fairweather
Family Lodge
Program
Application
7500 Hwy 90 West Bldg. 3, 
Mailing Address:
Office: (210) 208-5700 Fax:
Qualifications/Criteria
|
Stable on medication for at least
30 days |
|
|
Axis I Diagnosis from Physician |
|
|
At least 18 years of age |
|
|
Have children infant to 12 years
of age |
|
|
Free of drugs and alcohol for at
least 30 days |
|
|
Required to work 15-20 hours a
week or attend school within 30 days of entering program |
|
|
Must pay 30% of monthly income
for program fee |
|
Client
General Information: (Please fill out
completely) Date of
Application: ___________________
Name First and Last
Date of Birth Age SSN
Current Address
City, State, Zip
Current Phone Number
Are
you currently employed?
Are
you willing to work 15 to 20 hours a week?
Who
referred you to Fairweather Family Lodge?
Do
you have a psychological evaluation or a psychiatric evaluation?
Who
is your psychiatrist? (Provide name and phone number)
How
many children will you be bringing with you to the program?
What
are the ages of the children you are bringing with you?
Are
you currently involved with Child Protective Services? If yes,
provide name and phone number of Case Worker
Are you receiving SSI, SSDI, or
any other benefits (VA, Retirement) _______________________________________
If yes, which one(s)?
_____________________________________________________________________________
Have you applied for SSI, SSDI or any
other Benefits? __________________________________________________
How long do you plan on staying in
the program? ______________________________________________________
Please Check Your Total Monthly Income and then
the Source of the Income: Ex: SSI, SSDI, Medicaid, etc
Monthly
Income Income Source
□ No Income
□ $1 - $500 _____________________________________________
□ $151 - $250 _____________________________________________
□ $251 - $500 _____________________________________________
□ $501 - $1000 _____________________________________________
□ $1000 - $1500 _____________________________________________
□ $1500 - $2000 _____________________________________________
□ $2000 + _____________________________________________
Substance Abuse: Have you ever used any of the following? (Please check all that apply)
£ Tobacco Last
Used
£ Alcohol Last
Used
£ Marijuana Last
Used
£ Cocaine Last
Used
£ Crack Last
Used
£ Heroin Last
Used
£ Methamphetamine Last
Used
£ Over the counter medication Last
Used
Treatments for chemical use:
List the year of treatment, name of facility and location below
Year Name
& Location
Year Name
& Location
Year Name
& Location
Year Name
& Location
Mental
Diagnosis Information: (Please answer the following questions)
What is your mental health diagnosis?
Have you ever been hospitalized for mental
health problems?
If yes, then please list the dates and
locations below:
Year Hospital (Name and Location
Year Hospital (Name and Location
If you are prescribed medication for your
mental health diagnosis, please list names and dosages below:
Name of
Medication Dosage & Frequency
Name of
Medication Dosage & Frequency
Name of
Medication Dosage & Frequency