RESIDENT APPLICATION

1

NAME* This field is required.

First Name

Middle Name

Last Name

2

EMAIL* This field is required.

example@example.com

3

Phone Number* This field is required.

Area Code

Phone Number

4

DATE OF BIRTH* This field is required.

Date

5

SOCIAL SECURITY NUMBER* This field is required.

6

MARITAL STATUS* This field is required.

7

DO YOU HAVE ANY CHILDREN?* This field is required.

YESNO

8

DO YOU HAVE A VALID DRIVER'S LICENSE?* This field is required.

YESNO

9

UPLOAD FRONT OF DRIVERS LICENSE

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

10

UPLOAD BACK OF DRIVERS LICENSE

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Select files to upload

Max. file size: 10.6MB

11

DO YOU OWN A VEHICLE?* This field is required.

YESNO

12

IF YOU DO NOT HAVE DRIVERS LICENSE. DO YOU HAVE A VALID STATE ID?

YESNO

13

UPLOAD FRONT OF STATE ID PLEASE INCLUDE A COPY OF THE FRONT AND BACK

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Select files to upload

Max. file size: 10.6MB

14

UPLOAD BACK OF STATE IDPLEASE INCLUDE A COPY OF THE FRONT AND BACK

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Select files to upload

Max. file size: 10.6MB

15

DO YOU HAVE ANY VIOLENT OFFENSES? * This field is required.

YESNO

16

IF YES, PLEASE EXPLAIN. VOILENT OFFENSES

17

HAVE YOU BEEN CHARGED WITH THEFT, BURGLARY OR ARSON?* This field is required.

YESNO

18

IF YES, PLEASE EXPLAIN. THEFT AND BURGLARY CHARGES

19

ARE YOU ON THE SEX OFFENDER REGISTRY?* This field is required.

YESNO

20

DO YOU HAVE ANY OUTSTANDING WARRANTS* This field is required.

YESNO

21

IF YES, PLEASE EXPLAIN?

22

WILL YOU BE LEGALLY MANDATED TO OUR PROGRAM?* This field is required.

YESNO

23

ARE YOU ON PROBATION OR PAROLE?* This field is required.

YESNO

24

IF YES, PLEASE GIVE PROBATION OFFICER'S NAME AND CONTACT INFORMATION?

NAME

PHONE NUMBER

EMAIL ADDRESS

COUNTY

25

IF YES, PLEASE TELL US WHAT YOU ARE PROBATION FOR?

OFFENSE

START DATE

END DATE

26

HAVE YOU INFORMED YOUR PROBATION OFFICER THAT YOU WILL BE IN OUR PROGRAM?* This field is required.

YESNO

27

DOES YOUR PROBATION OFFICER REQUIRE US TO SEND THEM A MONTHLY REPORT?* This field is required.

YESNO

28

EMERGENCY CONTACT #1* This field is required.

NAME

PHONE NUMBER

29

EMERGENCY CONTACT #2

NAME

PHONE NUMBER

30

EMERGENCY CONTACT #3

NAME

PHONE NUMBER

31

WHEN WAS YOUR LAST RELAPSE?* This field is required.

Date

32

WHAT IS YOUR SUBSTANCE OF CHOICE?* This field is required.

33

HAVE YOU BEEN CLINICALLY DIAGNOSED WITH ANYTHING? * This field is required.

YESNO

34

IF YES, PLEASE EXPLAINCLINICAL DIAGNOSIS

35

DO YOU HAVE ANY HEALTH PROBLEMS?* This field is required.

YESNO

36

IF YES, PLEASE EXPLAIN?HEALTH PROBLEMS

37

DO YOU HAVE ANY ALLERGIES?* This field is required.

YESNO

38

IF YES, PLEASE EXPLAIN?ALLERGIES

39

ARE YOU CURRENTLY UNDERGOING MAT (MEDICALLY ASSISTED TREATMENT)?* This field is required.

YESNO

40

IS THERE A PLAN TO BE TAPERED OFF THESE MEDS?

YESNO

41

ARE YOU CURRENTLY TAKING ANY MEDICATIONS?* This field is required.

YESNO

42

MEDICATION #1

NAME

DOSAGE

QUANTIY

FREGQUENCY

PRESCRIBING DOCTOR

TAKEN FOR

43

MEDICATION # 2

NAME

DOSAGE

QUANTIY

FREGQUENCY

PRESCRIBING DOCTOR

TAKEN FOR

44

MEDICATION # 3

NAME

DOSAGE

QUANTIY

FREGQUENCY

PRESCRIBING DOCTOR

TAKEN FOR

45

TREATMENT CENTER #1* This field is required.

NAME

ADDRESS

START DATE

END DATE

TYPE

REASON FOR DISCHARGE

46

TREATMENT CENTER #2

NAME

ADDRESS

START DATE

END DATE

TYPE

REASON FOR DISCHARGE

47

TREATMENT CENTER #3

NAME

ADDRESS

START DATE

END DATE

TYPE

REASON FOR DISCHARGE

48

SOBER LIVING HISTORY #1* This field is required.

NAME

ADDRESS

ADMIT DATE

DISCHAGE DATE

LENGTH OF STAY

REASON FOR DISCHARGE

49

SOBER LIVING HISTORY #2

NAME

ADDRESS

ADMIT DATE

DISCHAGE DATE

LENGTH OF STAY

REASON FOR DISCHARGE

50

SOBER LIVING HISTORY #3

NAME

ADDRESS

ADMIT DATE

DISCHAGE DATE

LENGTH OF STAY

REASON FOR DISCHARGE

51

ARE YOU CURRENTLY EMPLOYED?* This field is required.

YESNO

52

IF YES, WITH WHOM ARE YOU EMPLOYED?

NAME

POSITION

53

TELL US ABOUT YOUR LIVING ARRANGEMENTS PRIOR TO MOVING INTO THIS FACILITY? * This field is required.

54

WHO REFERRED YOU TO THIS FACILITY?* This field is required.

NAME

56

WHAT WOULD YOU LIKE TO ACCOMPLISH DURING YOUR STAY AT SET FREE?* This field is required.

57

WHAT ARE YOUR TOP 3 GOALS FOR YOUR RECOVERY?* This field is required.

58

WHAT POTENTIAL CHALLENGES DO YOU SEE IN IMPROVING YOUR RECOVERY?* This field is required.

59

WHAT ELSE WOULD BE HELPFUL FOR US TO KNOW ABOUT YOU TO BEST SERVE YOU?* This field is required.

60

NAME

First Name

Last Name

61

DATE

Date

62

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In Progress

Done