Breakaway Application

The Breakaway

Resident Information/Application Form
Name
Phone Number
Date of Birth/Age
Sobriety/Clean Date
Address

Street Address

County

CityState / Province

Postal / Zip CodeCountry
SSN
Previous BA Resident? Y/N
Physical Difficulties:
Do you consider yourself Alcoholic/Addict:
What drugs are you dependent on:
Do you have a sponsor/Name of sponsor:
Physician prescribed medications:
Type a question
Have you been diagnosed with:

Bi-PolarDepressionMultiple PersonalitiesSchizophrenia
If yes to above, when:
Suicide attempts:
Do you see a Therapist or Psychiatrist:
Have you been convicted of any violent crime:
Have you been convicted of any sexual crimes:
Are you on probation/parole and where:
Lawyer and #:
Probation Officer and #:
Emergency Contact and #:
ARE YOU CURRENTLY IN JAIL, PRISON OR A TREATMENT FACILITY? IF SO WHEN WILL YOU BE RELEASED?blank
Number

The Breakaway