C3 A New Life, LLC

Application

By continuing, you agree that your electronic signature is the legally binding equivalent to your handwritten signature. Whenever you execute an electronic signature, it has the same validity and meaning as your handwritten signature. You will not, at any time in the future, repudiate the meaning of your electronic signature or claim that your electronic signature is not legally binding.

 

Are you ready to make a change?  

Radio buttons

 Has your life become unmanageable?

Radio buttons

 Are you ready to live a sober lifestyle?

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 Full Name: Client first nameClient last name 

Like to be called: Text field

Address:Client AddressClient CityClient StateClient Zip

Email:Client email

Phone:Client phone Type: Dropdown

Date of Birth:Client birthdate

Do you have any pending charges?

Radio buttons

If so, what are your charges? Paragraph

Are you a convicted Felon?

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Charged with? Paragraph

Are you on Probation/Parole?

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Officer's Name: Text field Phone # Text field

Email Text field

Can you pass a drug/alcohol screen?

Radio buttons

 If not, what substance(s) would show up? Paragraph

What is your sober date? RecoveryHistory

Are you currently employed?

Radio buttons

What Company? Text field Phone Text field

Address of Company: Paragraph

Emergency Contact: Text field

Emergency Contact Phone: Text field

Emergency Contact email: Text field

Other people we can disclose information regarding your recovery?

1 - NAME: Text field

PHONE Text field EMAIL Text field

2 - NAME: Text field

PHONE Text field EMAIL Text field

3 - NAME: Text field

PHONE Text field EMAIL Text field

4 - NAME: Text field

PHONE Text field EMAIL Text field

Are you currently in a relationship?

Radio buttons

If so, Name of partner? Text field

Phone number of partner? Text field

I agree C3 A New Life, LLC can lawfully contact any names you have mentioned above including your Parole/Probation officer, partner/significant other, emergency contact and/or others regarding your participation, attendance, willingness to comply and how you're doing  in regards to your recovery?

Radio buttons

Signature

FORMS OF IDENTIFICATION:

 

Do you currently have a valid Driver's License or state ID? Dropdown

ID or License# Text field State Text field

Expiration Date: Date

Do you have a valid SS card?  Dropdown

ID#Text field

Do you have a valid Passport? Dropdown

ID# Text field

Expiration Date: Date

Do you have a birth certificate? Dropdown

Are you  currently eligible to work in the United States?

Radio buttons

What medications are you currently taking? Paragraph

Are you willing to give up medications not deemed appropriate by C3?

Radio buttons

I am fully aware of the program rules, standards, what is expected of me, program fees and fines and my living situation, This is a voluntary application for me to live sober at C3 “A New Life”

 

Signed Signature Date: Date

 

RESPONSIBLE PARTY

Please choose one:

OPTION 1:  I am fully responsible and capable for paying all of my program dues/fees charged and disclosed to me at signing to enter the program. Furthermore, I agree to pay reasonable attorney fees on behalf of C3 if needed to collect any unpaid balance I owe if I leave the program willingly or unwillingly.

OPTION 2:  Someone else will be paying my fees and accepts to be the responsible party for any fees and dues associated to my admittance.  The responsible party must sign, provide 2 forms of acceptable documentation per IRS tax form guidelines and fill out the form below in order for you to complete the intake process.  If you can not afford to pay your fees and support your personal living expenses you will not be able to enter the program. The responsible party agrees to pay any reasonable attorney fees for C3 to collect any unpaid debt on behalf of me.

Checkboxes

Responsible Party Name: Text field Relationship Dropdown

Date: Date

Signature

 

 Responsible Party Forms of ID if NOT SELF PAY

By continuing, you agree that your electronic signature is the legally binding equivalent to your handwritten signature. Whenever you execute an electronic signature, it has the same validity and meaning as your handwritten signature. You will not, at any time in the future, repudiate the meaning of your electronic signature or claim that your electronic signature is not legally binding.

 

1st Type of ID Text field Expiration Date Date

Initial Copy given Initials Text field

 2nd Type of ID Text field Expiration Date Date

Initial Copy given Initials Text field 

 

Address of Responsible Party: Paragraph

Responsible Party Phone# Text field Email: Text field

Date: Date

Responsible Party Signature: Signature