Form

Address *

Phone Number *

- Area Code Phone Number
E-mail *
Insurance information *
Are you an alcoholic *

Yes No
Date of last drink
Are you addicted to drugs *

yes No
Date of last use & Drugs used *
Are you currently taking Prescription Drugs *

Yes No
What are they *
Are you currently on probation? *

Yes No
Type Name of Probation officer?
County of Probation
Reason you are on Probation?
Do you have and warrants Or restraining orders? Please list.
Pending Court Dates and where
Have you been diagnosed by a medical professional with any medical conditions, if so what are they and are you receiving treatment for them?
Have you had a TB Test? If so when and what was the result?
EMERGENCY CONTACTS
Full Name

First Name Last Name
Phone Number

- Area Code Phone Number
Additional information
Signature
Should be Empty:

New Beginnings Recovery Center Application