VisionQuest Online Application Form

VisionQuest Online Application Form
Name

First NameLast Name
Birth Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Gender
Email
example@example.com
Phone Number
Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Information
Are you on government assistance? (Welfare, disability, PWD, EI, etc.)
What substances are you struggling with?
Have you ever been diagnosed schizophrenic, or bi-polar?
Do you experience any anxiety, depression, PTSD, or ADHD?
Do you struggle with any self-harm or suicidal thoughts?
Do you have any medical disorders (Epilepsy, diabetes, and Hepatitis, HIV, autoimmune disease etc.)
Have you had any hospitalizations in the last 30 days? If so, please elaborate.
Have you had a tuberculosis (TB) test in the last 3 years?
List out all current medications
List all allergies
Have you ever been charged or convicted of any sexually related offences, arson or any crimes against minors?
Do you currently have any criminal charges? If so, who is your lawyer, and are you on bail, or probation? (This does not determine your eligibility)
Is there anything else that you would like us to know?
What days work best to contact you?
What time works best for you?
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: