Application

Application

Please answer each question
Today’s Date

MonthDayYear
Date
Name

First NameLast Name
Are you currently incarcerated? blanks If so, where? blank .
Are you in a facility (hospital, etc)? blanksblank
Phone Number
Please enter a valid phone number.
Date of birth

MonthDayYear
Date
IPO name: blanks DOC#: blank
Emergency Contact Information
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Relationship blanks
Age: blanksSSN: blank
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Employment Information
Are you employed? blanks Name of employer? blank
Family Information
Marital status blanks Do you have children? blank
Ages: blanks Do they live with you? blank
If not, who do they live with? blanks Do you have custody? blank
Are you sexually active? blanks heterosexual, homosexual, bisexual: blank
Is there any possibility that you are pregnant? blanks If so, how many weeks? blank
Educational Information
What is the highest grade you have completed? blanks If you do not have your HS diploma, are you interested in furthering your education? blank
Spiritual Information
Do you have a spiritual or religious affiliation? blanks Do you or have you attended church? blank
Describe your spiritual condition at this time blanks blank
Insurance and Services Information
Do you have insurance? blanks Private, Medicare, Medicaid? blank
Do you receive social security disability? blanks Other government assistance? blank
Do you receive food stamps? blanks If not, are you eligible? blank
Have you been denied food stamps in the last 90 days?blanks If so, for what reason? blank
Medical Information
Physician’s Name: blanks
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Do you or have you received mental health treatment? blanks If so, where? blank
How many hospitalizations have you had, if any? blanks
Please list the medication you take(A), who prescribes it(B), your dosage(C), and the reason you take it(D)
List what substances you have used(A), when you last used(B) and the frequency of use(C)
Primary “drug of choice" blanks Have you had any incidences of overdose/how many blank
Do you understand that we do not participate in MAT/MOUD treatment, including Suboxone/Methadone? blanks
List pending charges and legal action against you.
Civil charges? blanks Criminal charges? blank
Future court dates blanks Current/pending felony charges? blank
Treatment History
Have you been in treatment/recovery support programs? blanks If so, where? blank
If it’s discovered that you have knowingly given false information in this application, it may be grounds for immediate termination from the program. Do you understand this? blanks
Signature

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Application

Emergency Contact Information

Employment Information

Family Information

Educational Information

Spiritual Information

Insurance and Services Information

Medical Information

Treatment History