The Manna House - New Start Program Enrollment Application

The Manna House - New Start Program Enrollment Application
Applicant Details
Name

First NameMiddle NameLast Name
Has the applicant been a resident at the Manna House before?

YesNo
If yes, when?

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Date of Birth

MonthDayYear
Date
Social Security Number
Driver's License OR State ID Number & State Issued
Marital Status
Race / Ethnicity
Highest Level of Education Completed
Example: High School, Some College, College
Veteran Status, Branch & Time Served (If Applicable)
Religion / Faith
Parents and Spouse Details
Parent 1 Name (if applicable)

First NameLast Name
Parent 1 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent 1 Phone Number
Please enter a valid phone number.
Parent 2 Name (if applicable)

First NameLast Name
Parent 2 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent 2 Phone Number
Please enter a valid phone number.
Spouse (if applicable)

First NameLast Name
Spouse Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Spouse Phone Number
Please enter a valid phone number.
Emergency Contact Details
Emergency Contact Name

First NameLast Name
Relationship to Applicant
Phone Number
Please enter a valid phone number.
What are your reasons for enrolling in the New Start Program?
Are you willing to commit to a 12 month program? Yes No
Who will pay for recovery program expenses until you obtain employment?

First NameLast Name
Please enter a valid phone number.
While in the New Start Program, who will to receive progress reports of your recovery?

First NameLast Name
Please enter a valid phone number.
Medical History
Have you recently been in a treatment program? If so, please provide details.
Which substance(s) are you currently seeking recovery from?
Will you need to detox? Yes No

How long have you currently been continuously sober? Example: 12 days
Can you climb stairs without difficulty? Yes No

Can you read and write without difficulty? Yes No
Do you currently have any diagnosed physical/mental health conditions? If yes, please provide details.
Are you currently on any over-the-counter or prescription medications? If yes, please provide details.
Do you have a history of harming yourself? Do you have a history of thoughts of harming yourself? If yes, please provide details.
Do you currently have suicidal thoughts? If yes, please provide details.
Criminal History
Do you have a history of violent behavior? Do you have a history of having violent thoughts? If yes, please provide details.
Have you ever been convicted or arrested for a violent or sexual offense? If yes, please provide details.
Do you currently have any Emergency Protective Orders from/against any individuals?
Have you ever been to prison? If yes, please provide details of offense(s) and dates.
Are you currently on or expecting to be on probation or parole? If yes, please provide details in addition to your probation/parole officer's name and contact details.
Do you currently have any pending court appearances? If yes, please provide details.
Are you currently or expecting to have a court mandate to attend a long-term recovery program? If yes, please provide details.
Miscellaneous
Please let us know any other pertinent information.
How did you hear about the Manna House?
Should be Empty:

The Manna House - New Start Program Enrollment Application

Applicant Details

Parents and Spouse Details

Emergency Contact Details

Medical History

Criminal History

Miscellaneous