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.
First name Client first name
Last name Client last name
Are you currently in treatment?
If yes where?
When do you discharge?
Are you currently homeless?
Do you have a current address ?
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)
How did you hear about our program? (Be specific)
Drug of choice:
Client substances of choice
Have you ever been in a sober living program?
Sober living 1 name
Reason for leaving
Length of stay
Sober living 1 estimated length of stay
Please list all arrests and charges you have in your past. (if you do not have any legal history, please put NA)
# of times incarcerated Text field
Length of time spent incarcerated: Text field
What Counties were your charges Text field
Any pending charges?
Are you currently on probation?
List ALL substances you used addictively:
How did you use your drugs? (IV, Snort, Oral)
What age did you start using alcohol or drugs?
Have you ever been to Residential Treatment?
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:
What is your sobriety date?
Recovery history 1 sobriety date
Are you currently employed?
What kind of jobs have you had in the past?
If you are not employed or if you lose your employment you agree to obtain employment in 7 days?
Present marital status:
Client marital status
If single, do you have a significant other?
If yes, do you agree to delay that relationship for 6 months?
Spouse or Partner’s name: Contact 2 name
Years known: Text field
How do they support you in your recovery?
Do you have underage children?
Do you currently take any medications?
If yes, Are you med compliant?
If accepted, What do you want to achieve while participating in our program?
If accepted, What do you want to change in your life?
What positivity can you contribute to the residents of The Hope Society community?
Why should we accept you into our program?
Use this space for additional information you feel The Hope Society’s treatment team should know about you.
Thank you for your application! YOUR APPLICATION WILL ONLY STAY ACTIVE FOR 30 DAYS