Application

Service you are applying for

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Date of Birth

Marital Status

Are you currently on Probation or Parole?

Yes

If Yes, Please Provide the Probation Officers Name and Phone number

First Last Phone Number

Please list all charges

Please describe the conditions of your probation

Do you have an active protection order against somebody?

Yes

If accepted, We will need a copy

If yes, Please describe the individual

Recovery Information

Are you in Recovery From

Alcoholism

Drug Use

Do you take prescribed medication?

Yes

Please list and give reason being taken

Have you been in substance abuse treatment within the last 3 years?

Inpatient

Outpatient

List the name of program, dates attended, if you graduated, or if you were discharged - explain why

Are you currently in a self-help recovery or other recovery program

Please explain

Do you have a Sponsor

Yes

Are you now, or will you be on a medication assisted treatment (i.e. Methadone, Suboxone)

Yes

Employment

Employer

Business Name First Name Last Name

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Weekly Net Income

How long have you been at this job?

Disability Income per Month

Other Income

List your two most recent residences

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date

Reason for Leaving

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date

Reason for Leaving

Emergency Contact Information

In case of relapse, Contacts will be notified

First Last Phone Relationship