Client Application

This form is for potential clients that are currently incarcerated in prison or jail. Please complete ALL fields with asterids (*) 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

General

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

*Birthdate?

Client birthdate

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

  

Contact Information

*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

 

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

*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

 

Medications
 

*Are you on any medications? Dropdown

*List ALL the medications you are currently prescribed.

 

*Medication

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' applications.

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

 

 

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

Submission

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.