Resident Application
Name
*
First Name
Middle Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Alternate Phone
-
Area Code
Phone Number
Current Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
E-mail
Alternate email
Date of Birth
*
-
Month
-
Day
Year
Date Picker Icon
Sobriety Date
*
-
Month
-
Day
Year
Date Picker Icon
Drug(s) of Choice
*
Opiates (pain meds, heroine, methadone, suboxone, etc...)
Benzodiazepines (xanax, vallium, adavan, klonopin, versed, etc...)
Alcohol
Marijuana
PCP
Methamphetamines
Cocaine (including crack)
Sleeping pills or sedatives (lunesta, ambien, etc...)
Other (fill out next entry)
Other drugs
Current Health Insurance provider
*
Current medical conditions you are being treated for
*
Current medications (name, strength, and frequency of use)
*
Name and number of current health care providers (including counselors, therapists, and psychiatrists)
*
Current pharmacy(s) name and number.
Allergies (drugs, food, substances, etc...)
Emergency contact
*
First Name
Last Name
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact Phone
*
-
Area Code
Phone Number
Emergency Contact Alternative Phone
-
Area Code
Phone Number
Emergency Contact E-mail
List of names and numbers of those you wish to be able to inquire about your status
If anyone contacts us about you no information will be give out at all unless their name is listed here. We will not even confirm if you are a resident.
Veteran Status
*
Not a vet
Army
Navy
Airforce
Marine
National Guard
Air National Guard
DOD
Coast Guard
Other
List any social support or entitlements you are receiving (welfare programs like food stamps, child support, alimony, housing assistance, etc...)
*
List any social support or entitlements that you have applied for and are still pending
List any social support or entitlements you have applied for but were denied
Name of substance abuse treatment plans attended (Hope house, Pathways, Kolmac, etc...)
Name and number of current sponsor (if any)
Are you currently a felon?
*
Yes
No
Current charges (if any)
Are you currently on parole or probation?
*
Yes
No
What are the conditions of your parole/probation?
Current employer name, number, and address(if any)
Education
High School or GED
Associates Degree
Bachelors Degree
Masters or greater
Specialized training
Other
List of specialized training, professional certificates, and job skills
Hobbies and other pastime activity (musician, cards, excercise, etc...)
Current source of income
How do you plan on paying your program fees, personal bills, and other expenses while here?
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