Please complete your therapist's contact details at the end of the application Have you ever been hospitalised for emotional /psychological Yes No problems? Give details below, including dates and length of hospital stay: Have you ever been part of another residential programme like City Yes No Hearts? If so, what was the result? Please add their details to the references section of this form. We will need to contact them. Do you have a history of self-harm? Yes No Give details below of how frequently this occurs or has occurred in the past: Have you ever had suicidal tendencies or made an attempt before? Yes No Give as much detail as possible of what you planned, including dates: Do you smoke? Yes No How many per day? When did you start smoking? Have you ever tried quitting before? Yes No Are you interested in smoking cessastion? Yes No Please note that City Hearts Housing has a zero tolerance policy for residents smoking within its premises Do you drink alcohol regularly? Yes No What kind of alcohol do you drink, how much & how often? (Please provide as much detail as possible)
Please complete your therapist's contact details at the end of the application Have you ever been hospitalised for emotional /psychological problems? Yes No Give details below, including dates and length of hospital stay: Have you ever been part of another residential programme like City Hearts? Yes No If so, what was the result? Please add their details to the references section of this form. We will need to contact them. Do you have a history of self-harm? Yes No Give details below of how frequently this occurs or has occurred in the past: Have you ever had suicidal tendencies or made an attempt before? Yes No Give as much detail as possible of what you planned, including dates: Do you smoke? Yes No How many per day? When did you start smoking? Have you ever tried quitting before? Yes No Are you interested in smoking cessastion? Yes No Please note that City Hearts Housing has a zero tolerance policy for residents smoking within its premises Do you drink alcohol regularly? Yes No What kind of alcohol do you drink, how much & how often? (Please provide as much detail as possible)
Restore-Application-Form-18.docx