PLEASE NOTE YOUR APPLICATION WILL ONLY STAY ACTIVE FOR 30 DAYS! 

IF YOU WISH TO STAY ON OUR WAITING LIST YOU MUST

RE-SUBMIT YOUR APPLICATION EVERY 30 DAYS.

 

Date: Date

 

First name Client first name 

Last name Client last name 

 

Are you currently in treatment?

Radio buttons

If yes where? 

Text field

When do you discharge? 

Date

Are you currently homeless? 

Radio buttons

Do you have a current address ? 

Radio buttons

If Yes....

Address: Client Address 

City: Client City

State: Client State

What is your Cell Client phone

Email address  Client email

DOB Client birthdate

Race Client race 

Gender Client gender

 Do you have transportation arrangements necessary for appointments? (Explain) 

Radio buttons 

How did you hear about our program? (Be specific) 

 Text field

Drug of choice:  

Client substances of choice

Have you ever been in a sober living program? 

Radio buttons   

Facility/program

 Sober living 1 name

 Reason for leaving

  Radio buttons

Length of stay

 Sober living 1 estimated length of stay

 

LEGAL

Please list all arrests and charges you have in your past. (if you do not have any legal history, please put NA)

Paragraph

# of times incarcerated  Text field

Length of time spent incarcerated: Text field

What Counties were your charges Text field   

Any pending charges?

Radio buttons

Are you currently on probation?

Radio buttons

 

  

 ALCOHOL/DRUG

List ALL substances you used addictively:

Paragraph

How did you use your drugs? (IV, Snort, Oral)

Text field

 What age did you start using alcohol or drugs?  

Text field

Have you ever been to Residential Treatment? 

Radio buttons

Please tell us about you alcohol and drug residential treatment experiences...

Facility Name Treatment center 1 name 

City Treatment center 1 city 

Type Treatment center 1 type 

Discharge Treatment center 1 reason for discharge

 Please use this space for more informtion on additional treatment centers: 

Paragraph

What is your sobriety date?

 Recovery history 1 sobriety date

 

EMPLOYMENT

 Are you currently employed?

Radio buttons 

What kind of jobs have you had in the past?

Text field

 

If you are not employed or if you lose your employment you agree to obtain employment in 7 days?

Radio buttons

 

RELATIONSHIP/FAMILY 

 

Present marital status:

 Client marital status

If single, do you have a significant other?

Radio buttons

If yes, do you agree to delay that relationship for 6 months? 

Radio buttons

Spouse or Partner’s name: Contact 2 name

 

Years known: Text field

How do they support you in your recovery? 

Paragraph

 

Do you have underage children?

Radio buttons

How Many? 

Text field 

 

Do you currently take any medications?

Radio buttons

If yes, Are you med compliant?

Radio buttons

 

If accepted, What do you want to achieve while participating in our program?

Paragraph

  

If accepted, What do you want to change in your life?

Paragraph

 

What positivity can you contribute to the residents of The Hope Society community? 

Paragraph

Why should we accept you into our program?

Paragraph

Use this space for additional information you feel The Hope Society’s treatment team should know about you. 

 

Paragraph

 

 

Thank you for your application!  YOUR APPLICATION WILL ONLY STAY ACTIVE FOR 30 DAYS