Fields marked with asterisk (*) are required:
*From [your-email]: *Subject: *Name: *Date:
*Current Mailing Address: *Last Known Physical Address: *States/Countries you have lived in:
*SSN: *Official DL/ID # *Age
*Date of Birth: *Cell Phone #: Race 1/ Race 2/Ethnicity:
*Languages Spoken/Written: *Religious Preference:
*Marital Status: singlemarriedwidoweddivorced
*Have you ever been in the military? yesno
*Do you receive social security or disability payments? yesno
If “yes” give reason or explanation here__
*Highest education level completed? Grade schoolMiddle schoolHigh schoolCollegeTrade schoolGED
Do you consider yourself: AlcoholicDrug AddictBothNeither
What are your drugs of choice? AlcoholBarbituratesCocaineHeroinMarijuanaAmphetaminesOpiatesPCPK2/SpiceSyntheticsOther
*Why are you seeking residence at the H.O.W. center?
*Are you in treatment at the present time ? yesno
Where ? How many times have you been to treatment including outpatient?
*When, where and outcome of treatment?
*Are you currently incarcerated? yesno
*Offender ID Number: What was the date and change of your last felony conviction?
List all charges and arrests you have received being specific on each one starting with most recent including date of arrest, city and state of arrest, and reason for arrest.
*Are you a sex offender? yesno
Will you have an electronic monitor? yesno
*Any aggravated charges? (this includes all robbery, murder, and bodily injury charges) yesno
*Are you (or will you be) on Probation or Parole? yesno
Probation/Parole Officer Name
Contact phone number:
*Any charges pending ? yesno
If yes, please explain
*Are you taking any prescribed medication ? yesno
If YES list all medications and the reason for taking them:
*Have you EVER tested positive for any communicable disease? HIVTBHerpesHepatitisOtherNo
When were you last tested?
Describe all tattoo’s you have:
*Have you ever been associated with any gangs? yesno
*Have you ever thought of committing suicide? yesno
If YES, when ?
*Have you ever attempted suicide? yesno
If YES, when?
*What is your profession or skill?
*Are you employed locally? yesno
If “yes”, where?
*Who should we contact in case of an emergency?
*Name:
*Address:
Phones Home: *Cell: Relation:
Name: Phone: Relation:
*How do you plan to pay program fees? WorkSSI/DisabilityUnemploymentOther
Please explain
*1. How will you change and do things differently this time to stay sober? 2. Explain exactly what the 12 steps mean to you? 3. What will have to happen for you to be able to drink/use drugs successfully?
*How did you hear about The H.O.W. Center? Treatment CenterAA/NA GroupProbation/Parole Dept.GoogleReferring Website
Who can we thank for referring you?
Add Any Additional information we need to know or you need to explain regarding any of the application questions here:
By signing and sending this application you are agreeing to abide by all rules and regulations we have here at The H.O.W. Center including daily meetings, a commitment to complete abstinence and continued sobriety and financial independence. AgreeDo Not Agree
