Program Application

Application for Residency

Please complete, truthfully and thoroughly.
Todays Date*
Mo./Day/Year
Applicant Information
Full Name*

First NameLast Name
Current Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
Date of Birth*

MonthDayYear
Sex*
The Well is a female facility
Marital Status / Children*
Marital Status and number of children
E-mail*
Approx. Arrival*
Mo./Day/Year
Are you a US Citizen?*

YesNo
If no, are you authorized to work in the US?

YesNo
Are you currently in treatment?*

YesNo
If yes, which one?
Name of Current Treatment
Are you currently incarcerated?*

YesNo
If yes, which correctional facility?
Name of jail or prison
References

Please provide character references
Full Name*

First NameLast Name
Organization
Relationship
Phone Number*

Area CodePhone Number
Name*

First NameLast Name
Organization
Relationship
Phone Number*

Area CodePhone Number
Previous Treatment
Facility
Date

MonthDayYear
Date
Treated For:
Did you complete the program?

YesNoOther
Facility
Date

MonthDayYear
Date
Treated For:
Did you complete the program?

YesNoOther
Criminal Background
Are you currently on probation/parole?*

YesNoPendingOther
If yes, which county/counties?
Do you have pending cases?*

YesNo
If yes, explain.
Have you ever been convicted of a violent crime?*

YesNo
If yes, explain.
Any sex related crimes?*

YesNo
If yes, explain each conviction.
Do you have any outstanding warrant?*

YesNo
If yes, explain.
Physical Health Condition
Do you have any current medical issues?*

YesNo
Please list your medications.
Name, Dose, Frequency
Do you have any special needs?
Physician Name

First NameLast Name
Clinic Name
Clinic Phone

Area CodePhone Number
Please be specific and thorough when answering the next two questions. We want to get to know you the best we can, and base most decisions on these next two questions.
What situations or circumstances led you to where you are today?*
Of all the options available why did you choose The Well as your next step in recovery?*
Signature*

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Application for Residency

Applicant Information

References

Previous Treatment

Criminal Background

Physical Health Condition