Application Name Name * Date of Birth * Phone Number * Email Address * Address City State - Select Province/State - Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon ==================== Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code Do You Have A Drivers License? Yes No Do You Own A Vehicle? Yes No Are You Employed? Yes No Employer Name Supervisor Name Martial Status Single Married In Relationship Number of Children Religious Affiliation Are You Receiving Government Benefits? Yes No If Yes, Which Benefits? Do You Have Any Legal Issues? Yes No Are You Currently On Probation? Yes No Please explain all previous and current legal issues / probation: Are You Currently in Drug Court? Yes No Please list all Medical Issues you are experiencing Please list any current Dental Issues Do you have any Physical Accommodations / Limitations? Yes No If so, please explain List all Medications you are currently prescribed Date of Last Physical Psychiatric Diagnosis TB Test Result Positive Negative HIV Test Result Positive Negative Please List All Substances Abused Length Of Use Sobriety Date Tobacco User Yes No Daily Amount Previous Treatment History Have you Attended AA or Other Meetings? Yes No Emergency Contact Name Emergency Contact Phone Relationship To You Emergency Contact Email Address Emergency Contact Address City State - Select Province/State - Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon ==================== Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip How Did You Hear About Us?
