Calvary House Men

HEALING AND RESTORING MEN FROM ADDICTION
Personal Information
Name*

First NameLast Name
Middle Name
Nickname
Phone Number*
Email Address
example@example.com
Date of Birth*

MonthDayYear
Date
Age*
Place of Birth
Today's Date

MonthDayYear
Date
Address
City
State
Zip Code
Drivers License Number or State ID Number
ID Type

Driver's LicenseState IDOther
Number
State
Take photo of yourself*

Emergency Contact Information
Name*

First NameLast Name
Relationship*
Phone Number*
Address
City
State
Zip Code
Are your parents still leaving?*

Both aliveFather onlyMother onlyBoth deceased
Father's Name

First NameLast Name
Mother's Name

First NameLast Name
Address
City
State
Zip Code
Are your parents separated or divorced?*

YesNo
Do you have siblings?*

YesNo
How many brothers?*
How many sisters?*

Marital Status/Children
Marital Status*

MarriedSingleSeparatedDivorcedWidowed
Wife's name

First NameLast Name
Reasons for Divorce or Separation*
Do you have any children?*

YesNo
How many children?
Names of children and ages
Are you subject to any alimony/child support payments?*

YesNo
How much?*

Education
Did you graduate from high school?*

YesNo
Which high school?*
Did you attend college?*

YesNo
What was your major and degree earned?*
Did you attend trade school?*

YesNo
Which trade?*
Did you complete trade school?*

YesNo

Work History
Are you currently employed?*

YesNo
Current Occupation
Years of Experience in Current Occupation
Company 1
Company 2
Company 3

Military Experience
Are you a veteran?*

YesNo
Branch of Service
Highest Rank
Years in Service
Discharge Date

MonthDayYear
Date
Discharge Type
Please explain reason for discharge
Were you ever court-martialed?

YesNo
If yes please explain reason for courtmartial

Alcohol/Drug Use History
How many rehabilitation centers have you attended?*

NoneOneTwoThree +
Please list any rehabilitation centers you have attended*
What is/are your drug(s) of choice?*
At what age was your first drinking/drugging experience?*
How has your drinking/drugging pattern changed?*
What is your longest period of sobriety in the past two years?*
When did you last drink or get high?*
What did you drink/use?*
Is there any other information about your drug or alcohol use you wish to share?*

Spiritual Background
What is your church affiliation?*
Do you have a personal relationship with Jesus Christ?*

YesNoNot Sure
Briefly describe your testimony and your walk with Christ since that time*

Personal References
Please provide three personal character references (at least one from a pastor or church staff).
Reference 1:
Name*
Relationship*
Phone Number*
Reference 2:
Name*
Relationship*
Phone Number*
Reference 3:
Name*
Relationship*
Phone Number*
Please sign here

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