Resident Application

Name

First Name

Last Name

Date of Birth

YYYY

Drug/Substance of Choice

Phone

(###)

###

####

Are you in treatment? If so, what facility?

What is the name, number and email address of your case manager?

Where would you go if not here? Who lives there?

Do you have children?

if so do you have custody of them? Where do they live? Is there a visitation schedule? Is CPS involved?

Are you currently in a romantic relationship?

Yes

Have you read through our policy and procedure manual?

Are you currently in a safe place?

Yes

I'm not sure

Any open court cases or warrants?

Yes or No. If yes, please explain

Are you on probation?

If so, in what county and is it reporting?

Have you ever been charged with a violent or sexual offense?

If yes, please explain

Are you currently on any meds?

If so, what meds, for how long have they been prescribed?

What is your mental health diagnosis?

Have you ever been clean/sober before?

If so when, what program, and do you have a sponsor?

Do you have a vehicle you would bring with you?

If so, is it insured?

Do you have a Birth certificate, Identification card, or Social Security card?

Yes

Do you have any questions?

resident application