Date of Application
Personal Information
First Name
Last Name
Date of Birth
Address Line 1 (May not be an institution address; must be a forwarding or "next of kin" address)
Address Line 2
City
County where you last resided
State
Postal Code
Social Security Number
Email
Phone (If you do not have a phone, please provide phone number of "Next of Kin")
Marital Status SingleMarriedDivorced/SeparatedWidowed
Valid Drivers License YesNo
Drivers License Number
Vehicle YesNo
Highest Level of Education Some High SchoolHigh School GraduateSome CollegeCollege GraduateGraduate or Professional School
Race/Ethnicity American Indian or Alaska NativeAsianBlack or African AmericanHispanic or LatinoNative Hawaiian or Other Pacific IslanderWhite
Military Service YesNo
Branch of the Military
Discharge Status
Date of Last Drink or Drug
Drug of Choice AlcoholMethamphetamineBenzodiazapineOpiatesMarijuanaK2SpiceHeroinCocaineEcstasyOther StimulantsOther
All Other Drugs Used
Were you Referred to Progress House YesNo
If yes, then Referred by?
Why are you motivated to be a resident?
Felony Convictions YesNo
State of Conviction
Currently on Parole or Probation
County of Parole or Probation
Probation Officer Name
History of DOC Incarceration YesNo
Pending Charges YesNo
DOC #
Description of Legal History (if None, state "None")
Are you currently being treated for a medical condition? YesNo
Describe Medical History
List All Current Medications
Are you currently seeing a counselor or therapist? YesNo
Describe Psychiatric History
Currently Employed YesNo
Current Monthly Income
Hourly Rate
Place of Employment
Employment Start Date
Emergency Contact Name
Relationship
Emergency Contact Phone Number
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