APPLICATION FOR ADMISSION

Transcription

1 APPLICATION FOR ADMISSION Name: Age: First Middle Last Have you ever applied to or lived at Next Step Recovery? When? Permanent Address: Street: City: State: Zip Code: Social Security #: DOB: Birthplace: Height: Weight: Hair Color: Eye Color: Race: DisKnguishing marks (taloos, scars): In case of emergency, no4fy: Telephone: ( ) RelaKonship: Married/CohabitaKng Family Informa4on Divorced/Separated Single/Never Married Spouse/Significant other s name: Do you have children? Applicant s Parents: Father s Name: Deceased: Address: City: State: Zip Code: Mother s Name: Deceased: Address: City: State: Zip Code:

2 Substance Abuse Informa4on (This informa4on is confiden4al and will not affect your applica4on) Please list in order of preference all drugs used; past to present. This must be completed. Drug Age at first use Amount used at peak Date of last use Have you ever lived in a recovery house before? If yes. Name: Where? When? How long? Why did you leave? Have you ever been in a treatment program? Name: Where? When? How long? Did you complete? If no Why did you leave? Do you consider yourself an alcoholic / addict? Do you currently have a sponsor? Are you working or willing to work the 12 steps? Are you currently alending AA/NA meekngs? If yes, how many per week? Date of last use of drugs or alcohol: Please be prepared to provide your most drug screen info. Legal Informa4on Are you currently on probakon? If yes, ProbaKon Officer s name: Where: Telephone: ( ) Are you on intense probakon? What is your current offense? List all Prior/Current ConvicKons: Offense DisposiKon Date of DisposiKon

3 If currently residing outside N.C. or have lived in states other than N.C., a criminal background check(s) for those states must be submi=ed with this applica@on. Have you ever commiled/been charged with arson? Have you ever been charged with cruelty to animals? Have you ever been charged/convicted of a violent crime? Have you ever commiled/been charged with a sexual crime? Financial Informa4on Do you have the funds to cover the entrance fee? Do you have legal idenkficakon? Do you currently have a job? Full / Part Kme (circle one) Name of company Telephone ( ) Supervisor s Name How long have you been employed? Do you have a current valid Driver s License? If yes, what is the Driver s License # and state issued: Do you have your own vehicle? If yes, what is the name of your car insurance agency? Policy # ExpiraKon date: If you don t have a vehicle, how do you intend to get to and from work (buses come by house every hour)? Outstanding debts (child support, installment loans, IRS, etc.) Arrangement for payments: Are you court ordered to pay child support? Amount? Are you behind? Do you receive any ongoing financial reimbursement for any reason? (Such as, SSI, Disability, Medicaid, Trust Fund, etc.) If yes, explain: If for some reason you cannot pay rent per week/month who can you call upon to help you? Name: Phone:

4 Educa4onal Informa4on High school graduate? GED? Last grade completed: College Graduate? Years completed? Difficulty reading? EducaKonal goals? Medical / Mental Informa4on List any medical/mental issues: Are you under a doctor s care? If yes, give name: Telephone: ( ) Do you have dental problems? Current DenKst: Telephone ( ) History of: Seizures TB Diabetes HepaKKs Have you ever been hospitalized in a mental insktukon? Reason for hospitalizakon: Voluntary Involuntary Outcome: List Hospital(s) and Date(s): Have you ever been diagnosed with a learning disability? If yes, which one? Are you being treated for this disability? Have you ever heard voices? Diagnosis: Have you ever had visual hallucinakons? Diagnosis:

5 Are you suicidal? Have you ever tried to commit suicide? Explain: Have you ever been diagnosed with Bipolar Disorder? Have you had a TB test in the last year? PosiKve or negakve: Are you currently on medicakons? If yes, list names and reason for taking (prescribed and over- the- counter) Have you ever been tested for HIV? Date Results Have you ever been a vickm of a violent crime? If yes, please explain: On a scale of 1 to 10, how serious a problem do you think you have with drugs or alcohol? (circle one) No problem Very serious On a scale of 1 to 10, how mokvated are you to make changes in your life at this Kme? (please be honest) Not at all Very mokvated Affirma4on I affirm that my answers and informakon provided by me in this applicakon are true and accurate. I understand that if I am accepted, any misinformakon and/or dishonest answer may be grounds for my dismissal. Signature: Date: Witness: Date: