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Applicant Information
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Alternate Phone Number
Please enter a valid phone number.
Age*
Date of Birth*

MonthDayYear
Date
Marital Status *
Are you a registered sex offender?*

YesNo
Do you have a Valid Driver's License?*

YesNo
Do you have transportation?*

YesNo
Are you allergic to dogs?*

YesNo
Can you commit to a 90-120 day program?*

YesNo
Where are you currently staying?*
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?*

YesNo
Are you able to work at least 32 hour per week?*

YesNo
Are you currently receiving food stamps?*

YesNo
Health Information
What is the condition of your health?*

ExcellentGoodFairPoor
Do you have a disability?*

YesNo
What type of health insurance do you have?*
If yes, what Medicaid provider/plan do you have?*
Do you have a mental health diagnosis?*

YesNo
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?*

YesNo
Have you ever been to treatment/detox for alcohol/substance abuse?*

YesNo
If yes, when is the most recent time you went to treatment?*
Can you pass a alcohol/drug screen?*

YesNo
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?*

YesNo
Are you currently in Jail/Prison?*

YesNo
Are you on Parole/Probation?*

YesNo
Referral Source Information
Are you being referred?*

YesNo
If referred, please list the name of organization/person referring you *
Referring Organization/Persons phone number*
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Applicant Information

Employment Information

Health Information

Alcohol and Substance Use Information

Criminal Background Information

Referral Source Information