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Applicant Information
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Alternate Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Age
*
Date of Birth
*
-
Month
-
Day
Year
Date
Marital Status
*
Please Select
Single
Married
Separated
Divorced
Widowed
Are you a registered sex offender?
*
Yes
No
Do you have a Valid Driver's License?
*
Yes
No
Do you have transportation?
*
Yes
No
Are you allergic to dogs?
*
Yes
No
Can you commit to a 90-120 day program?
*
Yes
No
Where are you currently staying?
*
Please Select
Substance Abuse Facility/Rehab
Living alone
With Family
With Friends
Jail/Prison
Hotel/Motel
Psych Hospital
Hospital
Emergency Shelter
Streets
If in substance abuse/rehab facility please provide patient ID number and counselor's name
*
If in substance abuse/rehab facility what is your projected discharge date?
*
Employment Information
Are you currently employed?
*
Yes
No
Are you able to work at least 32 hour per week?
*
Yes
No
Are you currently receiving food stamps?
*
Yes
No
Health Information
What is the condition of your health?
*
Excellent
Good
Fair
Poor
Do you have a disability?
*
Yes
No
What type of health insurance do you have?
*
Please Select
Medicaid
Medicare
Private Insurance
Tri-care
None
If yes, what Medicaid provider/plan do you have?
*
Do you have a mental health diagnosis?
*
Yes
No
If yes, please list mental health diagnosis
*
Please list prescribed medications
*
Alcohol and Substance Use Information
Do you have a history with alcohol and/or substance abuse?
*
Yes
No
Have you ever been to treatment/detox for alcohol/substance abuse?
*
Yes
No
If yes, when is the most recent time you went to treatment?
*
Can you pass a alcohol/drug screen?
*
Yes
No
If no, please list the drugs you would fail for and date of last use
Criminal Background Information
Have you ever been convicted of a crime?
*
Yes
No
Are you currently in Jail/Prison?
*
Yes
No
Are you on Parole/Probation?
*
Yes
No
Referral Source Information
Are you being referred?
*
Yes
No
If referred, please list the name of organization/person referring you
*
Referring Organization/Persons phone number
*
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