Apply

1. First Name

Client first name

2. Last Name

Client last name

3. Birth Date

Client birthdate

4. Phone Number

Client phone

5. Email

Client email

6. Street Address

Client Address

7. City

Client City

9. State

Client State

10. Zip Code

Client Zip

11. Drug of Choice

Client substances of choice

12. Sobriety Date

Date

13. Do You Have Two (2) Forms of ID?

Checkboxes

14. What Forms of ID Do You Have?

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15. Do You Have a High School Diploma or GED?

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16. How Were You Referred to Us?

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17. Are You Recieveing Social Security Benefits or Any Other Assistance?

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18. Reincarnation Cottages Requires You to Work a Full Time Job as Part of Our Program. Are You Willing to Work Full Time?

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19. Is There Any Reason Why You Wouldn't be Able to Work a full Time Job?

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20. What Trade Are You Skilled In?

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21. Do You Have Any Court Appearence's in The Next 12 Months?

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22. Do You Have Any fines That You Are Paying or Need to be Paid?

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23. Are You a Parent?

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24. Have You Ever Been Convicted of a Felony or Misdemeanor Other Than Traffic Offenses?

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25. Are You Willing to Have a Criminal Background Check Performed?

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26. Are You Willing to be Regularly Drug Tested?

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27. Are You Currntly Taking Any Medications?

Medication

28. Are You a Registered Sex Offender?

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29. When Do You Expect to be Ready to Move In?

Date

30. Emergency Contact Information

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