Contact Us Contact Information Location 2604 N Parham Rd. Henrico, VA 23294 Email admin@thewarfoundation.org Office 804-593-1131 Mobile 804-237-4011 "*" indicates required fields PersonalName**Date of Birth* MM slash DD slash YYYY Age*Gender*Date of Arrival* MM slash DD slash YYYY Contact InfoBest time to contact*Phone Number **Email* AddressAre you filling out this form for someone else? Yes No Your nameRelationshipYour numberYour EmailCriminal HistoryAre you currently incarcerated? Yes No Do you have pending court cases? Yes No If so and you need court advocacy please provide attorney phone and email addresses.Attorney PhoneAttorney Email AddressAre you on probation/pretrial or involved in any reentry or criminal justice program? Yes No Do you have a criminal history? Yes No If so please explainHave you ever been convicted of a violent crime? Yes No If so, please provide detailAre you a registered sex offender or have you been convicted of any crime sexual in nature? Yes No Medical InfoDo you have any mental health diagnosis? Yes No Do you utilize MOUD (Medication for Opiate Use Disorder)? Yes No If yes, please explain medication plan, provider and dosageDo you take medications? Yes No Please list medications.Do you have all of your needed medications or do you need assistance with linkage to providers? Yes No Do you have any medical conditions that would require medical attention in next six months? Yes No Do you have any conditions that limit your mobility or compromise your ability to use steps or get on a top bunk? Yes No Have you ever been hospitalized for your mental health? Yes No Please explain.Other InfoAre you able to work or currently working? Yes No If so where and what are your hours?Are you able to pay your weekly bed fees? Yes No Are you in the process for filing for disability? Yes No Have you ever resided with The WAR Foundation? Yes No Have you been in any other recovery programs in the last 2 years? Yes No If so where and for how longHave you participated in any PHP/2.5 in the last year or any other clinical programs? Yes No Do you have insurance? Yes No Please list insurance type and provider?What is your last date of use? MM slash DD slash YYYY What is your drug of choice?Do you consider yourself suffering from Substance Use Disorder? Yes No
