Step 1) Application: Form C - General Public

Client Application

Please complete ALL fields with astrid (*) before submitting.

Client Referral Source

*Who referred you to Wings of Freedom?

Text field

*Reason for applying? Paragraph

*What is your expected move-in date? Date


Full name? Client first name Client middle name Client last name

*Birthdate? Client birthdate Text field Gender Client gender Race/ethnicity? Client race

*Clients Social Security Number: SSN

*Marital status? Client marital status Spouse Text field

Maiden name? Text field

*Are you enrolled in a tribe? Dropdown

Are you a veteran? Client veteran status

Contact Information

*Cell phone number? Client phone Email address? Client email 

*What is a good mailing address? 

Client AddressClient CityClient StateClient Zip


Medical History

*Do you have 30 days of sobriety? Dropdown

*Can you pass a drug and/or an alcohol test? Dropdown

*What is your substance(s) of choice? Client substances of choice

*Have you been clinically diagnosed with anything? Client diagnosis

*Do you have any health problems? Client health problems


Additional medical notes.

Client medical notes



*Are you on any medications? Dropdown

*List ALL the medications you are currently prescribed.


Additional medication notes.

Client medical notes


 Criminal Background

We require all clients to have a background check before entering our program. Felonies will NOT disqualify clients application.

 Have you ever been convicted of a felony? Dropdown

*Have you ever been arrested for a "sex crime"? Dropdown

Do you now, or have you ever had any "gang affiliation"? Dropdown

*DOC Number: Text field

*Are you currently on probation/parole or drug court? Dropdown



*Source of Income: Dropdown


 Living Arrangement

*Have you ever been admitted to a drug/achocol treatment? Dropdown

*Have you ever lived in another sober living program? Dropdown

*Do you have any minor children? Dropdown

*Do you plan on your children living with you? Dropdown 

*Do you have an open DHS case? Dropdown

Text field Date Dropdown Dropdown
Text field Date Dropdown Dropdown
Text field Date Dropdown Dropdown
Text field Date Dropdown Dropdown
Text field Date Dropdown Dropdown
Text field Date Dropdown Dropdown


Spiritual Status

We are a faith-based sober living program. Let us know about your faith. This does NOT decline any potential clients from being accepted into the program if they have different beliefs. 

*What are your beliefs? Dropdown


Please do NOT leave any unanswered questions. If incarcerated, please attach a copy of your CRC card (consolidated record card).


Signature: Signature

Date: Date

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.