Still Worthy Resident or Participant Application Form

 Date

Client first nameClient middle nameClient last nameClient pronoun

 

Date desired for moving in if application is approved: Date

Applicant’s date of birth: Client birthdate

Social Security Number [Optional]: SSN

Substance of Use(Select all that apply): Client substances of choice

 

Phone Number: Client phoneCell phone Number:Client phone

Email address:Client email

 

Current physical address: Client Address

Mailing address if different than the above:Client Address

 

If employed, what is your monthly gross income: Text field

 

 

Marital status [Circle one]:    Client marital status       

Level of education completed:EducationHistory

 

Vocational education. [List specialty and/or certifications]:Paragraph

Are you a veteran Text field

Are you pregnant? [Circle one]:    Text field

Do you hold a valid driver’s license?  [Circle one]:  Text field

 

Do you have a car or motorcycle? [Circle one]:      Text field

If you do own one of the above, is the vehicle

fully insured and registered?  [Circle one]:Text field

TreatmentCenterHistory

SoberLivingHistory

 Medication

Allergies: Client allergies

 

Emergency Contact: Contact

Expected discharge date:Date

 

Who referred you to us? [Please print legibly]:Text field