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Woman Application

If you are applying for you and your child(ren), you must fill out child application in order for your application to be complete. 

Name (First, Middle, Last)*

Date Of Birth *

Age*

Phone*

Email Address*

Marital Status

Current Living Situation*

Current Address*

City*

State*

Zip Code*

Own A Vehicle? *

Year/Make/Model

Tag #

Valid Driver's License*

State

Driver's License/ or ID #*

Are you an alcoholic? *

Date Of Last Use*

Drug(s) of Choice*

Currently/recently in treatment? *

Name & Location of Facility

Did you complete successfully? *

Discharge Date

Name Of Counselor

How do you plan to stay clean and sober? *

Who referred you to Secrets Of The Heart Transitional Living, LLC.? (Name, Relationship, & Phone) *

Do you attend 12-step meeting? *

If so, how often?

Do you have a sponsor? *

Have you lived in a recovery house before? *

Name & Location of House

When/how long?

Why did you leave there? *

Why do you want to live at Secrets Of The Heart Transitional Living, LLC.? *

Are you employed? *

If Yes, Name & Location of Employer

Job Title

How Long Employed?

Current Monthly Income *

What other types of work have you done?

Special Skill/Training

If No, How long since last employed?

Are you willing/able to get a job within 14 days? *

Are you willing/able to be self supporting? *

Will someone else be helping you pay rent or deposit? *

Name/Relationship

Phone

Street Address

City

State

Zip Code

List Pending Charges/Cases/Warrants*

Ever been incarcerated?*

When/How Long?

Reason

Name & Location of Facility

Currently on probation/parole? *

Location of Office

Name of Officer

Phone

Are you a registered sex offender? *

List all medical/psychiatric conditions*

List all current medications*

Describe any injuries/disabilities *

Describe physical limitations resulting from disabilities *

Name of Physician

Are you receiving Suboxone, Subutex, Methadone, Vivitrol, etc? *

Physician Prescribing

Emergency Contact Name 1*

Relationship*

Phone *

Street Address

City *

State *

Zip Code

Emergency Contact 2*

Relationship*

Phone *

Street Address

City*

Zip Code

I have read all of the material on this application form. I have also answered each question honestly and want to achieve comfortable recovery from alcoholism and/or drug addiction without relapse. Someone will contact you in 24-48 business hours (excluding weekends). If you have any questions, please feel freet contact the COO/Program Director
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