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First Name
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Last Name
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Email
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Date of Birth
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Phone
Marital Status
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Single
Separated
Widowed
Married
Divorced
Do you have children?
*
Yes
No
Please list your children(s) name(s) and age(s)
Please list any/all medical conditions
Please list any/all medications your are taking/prescribed
Location History
Have you lived in a sober living home before?
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Yes
No
What sober living home(s), when and where?
Have you ever been asked to leave a sober living or treament program?
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Yes
No
Please explain
Legal Status
Are you currently on probation or parole?
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Yes
No
Probation Agent Name
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First
Last
Probation Agent Phone
Are you legally allowed to leave the county?
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Yes
No
Agent the terms,
Do you have any open charges?
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Yes
No
Please explain any open charges
Criminal Background
Have you ever been convicted of a felony?
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Yes
No
Please explain felony charges
Do you have any violent offense convictions?
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Yes
No
Please explain violent offenses
Do you have any sexual offense convictions?
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Yes
No
Have you ever been incarcerated?
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Yes
No
Please list date(s) of incarceration and facilities
Are there any restrictions (court orders, probation terms, registry requirements) that could affect your residency?
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Yes
No
Please explain those restrictions
Substance Use and Recovery History
Primary substance(s) used
Date of last use
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Do you have a sponsor?
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Yes
No
Are you currently in treatment?
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Yes
No
Treatment Center Name, Counselor Name and Contact Information
Employment and Financial Information
Current employment status
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Employed
Unemployed
Student
Please list your employer and address
Do you agree to pay your program fees in full?
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Yes
No
Acknowledgement
I hereby certify that the above information is true and accurate to the best of my knowledge. I understand that false or incomplete information may result in denial of admission to Redemptions Recovery.
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