This form is for potential clients that are currently incarcerated in prison or jail. Please complete ALL fields with asterids (*) before submitting.
*Who referred you to Wings of Freedom?
*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 statusSpouse Text field
Maiden name? Text field
*Are you enrolled in a tribe? Dropdown
Are you a veteran? Client veteran status
*Do you have children? Dropdown
How many children do you have? Text field
*Do you plan on your children living with you? Dropdown *Do you have an open child custody case? Dropdown
*What is your DOC number? Text field
*What is your DOC case manager information? Text field Text field Text field
*What is a good mailing address?
Client Address Client City Client State Client Zip
*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
*Have you ever been admitted to a drug/alcohol treatment? Dropdown
*Have you ever lived in another sober living program? Dropdown
Additional medical notes.
Client medical notes
*Are you on any medications? Dropdown
*List ALL the medications you are currently prescribed.
Additional medication notes.
What is the date of your last misconduct? Date
*Have you ever been convicted of a "sex crime"? Dropdown
Do you now, or have you ever had any "gang affiliation"? Dropdown
*What type of release? Dropdown
*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).
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.