AA Rehabilitation Homes Online Application

AA Rehabilitation Homes Online Application

Please complete this application to help us understand your background and needs for residency at AA Rehabilitation Homes.
Full Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Emergency Contact Name and Relationship
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
How did you hear about AA Rehabilitation Homes?
Can you read and write English?
What grade did you complete?
Do you have any pending legal matters? Please describe.
What are your controlling issues (e.g., substance use, behavioral concerns)?
Have you had prior treatment or attended any other programs for these issues?
If yes, provide the name of the facility and why you left.
Are you a registered sex offender?
If yes, please explain and include any restrictions you have.
Have you been convicted of any violent crimes?
If yes, please explain.
Do you have any diagnosed medical conditions (including STDs)?
If yes, please explain.
Have you been diagnosed with any mental health disorders (e.g., bipolar, schizophrenia, etc.)?
If yes, please explain.
Do you take any medications?
If yes, what is the name of the medication and how do you plan on paying for your medication while at AA Rehabilitation Homes?
Do you have any physical limitations?
If yes, please explain.
Are you a Christian?
If yes, for how long and what denomination?
If you are not a Christian, do you identify with any other religion or belief system?
WHAT DRUGS HAVE YOU USED MORE THAN 2 MONTHS AT A TIME IN YOUR LIFETIME?       (CIRCLE ALL THAT APPLY)

ALCOHOL                  CIGARETTES             COCAINE                   HALLUCINOGENS

INHALERS                  MARIJUANA              METH                          OPIATES

SEDATIVES                SOLVENTS                 STIMULATES             TRANQUILIZERS

OTHER NARCOTICS              OTHER ___________________________________________________

WHAT DRUGS HAVE YOU USED DURING THE LAST 12 MONTHS? (CIRCLE ALL THAT APPLY)

ALCOHOL                  CIGARETTES             COCAINE                   HALLUCINOGENS

INHALERS                  MARIJUANA              METH                          OPIATES

SEDATIVES                SOLVENTS                 STIMULATES             TRANQUILIZERS

OTHER NARCOTICS              OTHER
Are you willing to be mandated by the courts?
Are you willing to complete 12 months or more at staff or Court discretion?
Do you currently have a job?
If yes, where?
What are your work hours?
What do you hope to accomplish at AA Rehabilitation Homes?
Are you on Probation or Parole
If so what County? What is the name of your Parole or Probation Officer
Name of Person Completing Form

First NameLast Name
Relationship to Applicant
Signature
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