AA Rehabilitation Homes Online Application

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?*

YesNo

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)?*

YesNo

If yes, provide the name of the facility and why you left.

YesNo

If yes, please explain and include any restrictions you have.

YesNo

If yes, please explain.

YesNo

If yes, please explain.

YesNo

If yes, please explain.

YesNo

If yes, what is the name of the medication and how do you plan on paying for your medication while at AA Rehabilitation Homes?

YesNo

If yes, please explain.

YesNo

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

YesNo

If yes, where?

What are your work hours?

What do you hope to accomplish at AA Rehabilitation Homes?*

YesNo

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