Program Inquiry Questions:
First Name
*
Middle Name
Last Name
*
Preferred Name
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Is it safe for staff to leave a voicemail or text?
*
Yes
No
Email
*
example@example.com
Is it safe for staff to send an email?
*
Yes
No
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Alternate contact info if it is not safe to call, email, or leave a message:
Gender
*
Male
Female
Non-Binary
Other
Race
*
White
Asian
Black or African American
Native Hawaiian or Pacific
American Indian
Hispanic or Latino
Native Alaskan
Two or More Races
None or Refused to Specify
Other
Sexual Identity
*
Relationship Status:
*
Single
In a relationship
Common Law
Married
Separated
Divorced
Widowed
Military Service
*
Yes
No
What program are you interested in:
*
Providence House (single men and women in recovery)
Silver Lining House (young men in recovery)
Have you ever lived in one of our programs? If yes, which one
*
How did you hear about our program?
*
Providence Network staff or resident
Friend/Family
Treatment Center/Detox/Sober Living
Shelter
Case Worker/Counselor
Probation/Parole/Court
Church/Ministry
Other
Provide name or agency (for above question)
*
Are you employed?
*
Part-time
full-time
unemployed
unable to work
Do you have medical insurance?
*
Medicaid
Medicare
Other
Medicaid or medicare number, if known:
*
Do you have children that live with you?
*
Yes
No
Do you have any medical or mental health conditions that would limit your ability to work or participate in the program?
*
Do you have any substance abuse issues?
*
Current
Past
Never
Date of last use (drugs or alcohol)
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Legal Situation: (check all that apply)
*
On Probation/Parole
Open/Pending Case/Outstanding warrant
I have a crimes against persons charge (assault, DV, sexual offense)
Off paper
Not applicable
How can our program assist you:
*
Submit
Should be Empty: