Application Form

* Indicates required field

Name *

First

Last

Phone Number *

Birthdate *

Email *

Do you currently have a driver’s license? *

Yes No

Drivers License Number *

Do you currently have a vehicle? *

Yes No

Social Security # *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Any Medical Conditions? Please List Below *

Are you Married? *

Yes No

Do you have children? *

Yes No

Any medications you are currently taking. *

Please List drug of choice (DOC) Below: (example- Alcohol, Cocaine, Prescription Drugs) *

When was the last time you used drugs or alcohol? *

Have you been in a recovery program before: *

Yes No

Ever attended any meetings (AA, NA, Celebrate recovery): *

AA NA Celebrate Recovery None

Have you ever been arrested? *

Yes No

Misdemeanor convictions: *

Felony convictions: *

Do you have any warrants, pending charges and or upcoming court dates? *

.1 Emergency Contact (name and number): *

Currently on probation, parole, under bond? (if yes please list probation or parole officer name and contact info below) *

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