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Residential Program Application
Name
*
First Name
Last Name
Email
Date of Birth
*
MM
DD
YYYY
Race
Phone number
*
(###)
###
####
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Emergency Contact
*
First Name
Last Name
Relation to Applicant
*
Referred by
Person Completing Form
*
Relation to Applicant
Describe your relationship with your family
Do you have children?
*
Yes
No
Do you have a history with addiction?
*
Yes
No
Do you have a history with prostitution?
*
Yes
No
Do you have a history of sexual abuse?
Yes
No
Have you experienced domestic violence?
Yes
No
Are you currently in a romantic relationship? If yes, please explain.
Do you have medical insurance?
Yes
No
Have you received a Covid vaccine?
Do you receive SSDI?
Yes
No
Do you have a payee or conservator?
Yes
No
List any inpatient, A and D treatment, IOP, and/or recovery program in which you have participated.
Have you ever received a mental health diagnosis?
Yes
No
Do you have any physical disabilities, chronic or ongoing condition?
Yes
No
Are you currently taking any medications?
Yes
No
Have you been hospitalized for psychiatric reasons?
Yes
No
Have you ever attempted sucide?
Yes
No
Do you pending charges or warrants?
Yes
No
Are you on probation?
Yes
No
What is your highest level of education?
Describe your work history.
Thank you!
