Are you pregnant:
Do you think you have a problem with alcohol?:
Do you think you have a problem with drugs?:
Do you have a sponsor?
Do you have any other addictions or disorders: i.e. eating disorder, cutting, sex addict?
Have you been arrested in the past 30 days:
Are you currently on probation or parole:
Are you mandated here:
Please list any pending legal problems, i.e. Court dates, defaults, violations, warrants etc.
Do you have any active restraining orders against you or someone else?
Do you take any prescription medications:
Do you have any medical conditions or allergies?
Do you have a primary care physician:
Current work Schedule - Indicate Hours
List Last 2 Employers:
Are you receiving welfare, disability, assistance or other non-job related income?
Do you have a valid driver’s license?
Do you have a car:
If yes, is it registered and insured?
Have you ever lived in a home shared with other people?
Do anticipate any problems with sharing the responsibilities of a community home?
I authorize the verification of the information provided on this form as to my legal and employment.
Signature of applicant: