Application (lead form)

ANCHOR HOMES, INC

2333 MACCORKLE AVE

SAINT ALBANS, WV 25177

PHONE (681) 205-8548/  855-888-9316 FAX

 

Name    

Phone:  Recovery Date

Social Security Number:

Date of Birth 

Gender:

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Drivers License Number: State Issued: 

License Plate Number: 

Are you currently or have you been released from incarceration within the last 6 months? 

If yes, name the last facility? 

Did you use drugs at this facility? 

How long was you incarcerated:

Date of Release 

Are you required to register as a sex offender?

Name and phone number of Parole Officer 

How long on Parole? 

Pending Charges: 

Attorney Name/Phone # 

Name all programs completed while incarcerated: 

Please list all treatment programs, including detoxes, that you have participated in:


 


 

Are you currently experiencing any physical health or mental health symptoms? 

Are you currenly working with a sponsor? 

How long have you been in recovery?

What is your substance of choice? 

Are you currently employed? 


Last grade completed in school?


Vocational certifications/licenses   

Please include at least two emergency contacts?

       

 


 

By continuing, you agree that your electronic signature is the legally binding equivalent to your handwritten signature. Whenever you execute an electronic signature, it has the same validity and meaning as your handwritten signature. You will not, at any time in the future, repudiate the meaning of your electronic signature or claim that your electronic signature is not legally binding.

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