Application

Date:

Date

 

First name Client first name 

Last name Client last name 

 

Current Address Client Address 

City Client City

State Client State

Zip Client Zip

 Cell Client phone

Email address  Client email

DOB Client birthdate

Race Client race 

Marital Status Client marital status 

Gender Client gender 

Veteran Client veteran status

Emergency contact name:  Contact 1 name 

Phone Contact 1 phone 

Relationship Contact 1 type 

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

Radio buttons 

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

 Text field

What program are you applying for?   

Radio buttons 

Drug of choice:  

Client substances of choice

 

Have you ever been in a sober living program? 

Radio buttons   

Facility/program

 Sober living 1 name

City

 Sober living 1 city

Reason for leaving

 Sober living 1 discharged 

Length of stay

 Sober living 1 estimated length of stay

Please use this space to list any other sober living programs you have participated in.

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LEGAL

Please list all arrests and charges you have in your past:

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# 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:

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Do you consider yourself a drug addict?

Radio buttons

Alcoholic?

Radio buttons

What age did you start using alcohol or drugs?  Text field

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: 

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What is your sobriety date?

 Recovery history 1 sobriety date

How did you use your drug of choice? (IV, Snort, Oral) 

 Text field

 

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

Phone Contact 2 phone

Type Contact 2 type 

Years known: Text field

How do they support you in your recovery? 

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Children’s name  Age    Male/Female  Lives with

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MEDICAL

Mental Health treatment

FacilityTreatment center 3 name

City Treatment center 3 city 

Dischage Treatment center 3 reason for discharge

List all Diagnosis

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Do you currently take any medications?

Radio buttons

 

Are you med compliant?

Radio buttons

 

Do you agree to keep ALL medication locked up?

Radio buttons

 

List any trauma you have experienced:

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What do you want to achieve while participating I our program?

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What do you want to change in your life?

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Why do you want to enter our program?

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

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Why are should we accept you into our program?

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

 

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Thank you for your application!

 

Applicant Signature:Signature

Date:Date