Application

Name:
Email:
Date of Birth (mm/dd/yyyy):
Permanent Address:
City:
State:
Zip:
Phone #:
Social Security #:
Marital Status:
Date of Sobriety:
Longest period of sobriety (list dates):
Drug of Choice:
Dual Diagnosis?

If yes please explain the current treatment and medications being taken and name of attending physician		  yes
 no
Are you currently taking prescribed medication?

if yes please list the medication you are currently taking		  yes
 no
Are you allergic to any medication?

if yes please list		  yes
 no
Please list all the primary care treatment facilities you have attended, including name and dates:
Facility #1
Facility Type:  inpatient
 outpatient
Facility Name:
Dates:
Facility #2
Facility Type:  inpatient
 outpatient
Facility Name:
Dates:
Please provide the name of the counselor: you are currently seeing and his/her phone number:
Counselor Name:
Counselor Phone Number:
Your highest level of education completed:
Do you know of any history of alcoholism or addiction in your family?

if yes please explain		  yes
 no
Please list your job and special skills:
Do you have a valid drivers license?
if yes what state?		  yes
 no
Do you have a car that is registered?
if yes what state?		  yes
 no
Please provide the name and phone number of your nearest relative:
Relative Name:
Relative Phone Number:
Relative Relation:
Comments