1. First Name
Client first name
2. Last Name
Client last name
3. Birth Date
4. Phone Number
6. Street Address
10. Zip Code
11. Drug of Choice
Client substances of choice
12. Sobriety Date
13. Do You Have Two (2) Forms of ID?
14. What Forms of ID Do You Have?
15. Do You Have a High School Diploma or GED?
16. How Were You Referred to Us?
17. Are You Recieveing Social Security Benefits or Any Other Assistance?
18. Reincarnation Cottages Requires You to Work a Full Time Job as Part of Our Program. Are You Willing to Work Full Time?
19. Is There Any Reason Why You Wouldn't be Able to Work a full Time Job?
20. What Trade Are You Skilled In?
21. Do You Have Any Court Appearence's in The Next 12 Months?
22. Do You Have Any fines That You Are Paying or Need to be Paid?
23. Are You a Parent?
24. Have You Ever Been Convicted of a Felony or Misdemeanor Other Than Traffic Offenses?
25. Are You Willing to Have a Criminal Background Check Performed?
26. Are You Willing to be Regularly Drug Tested?
27. Are You Currntly Taking Any Medications?
28. Are You a Registered Sex Offender?
29. When Do You Expect to be Ready to Move In?
30. Emergency Contact Information