First Name

Middle Name

Last Name

Date

Address

City

State

Zip

Phone

Date of Birth

Age

Social Security Number

Driver License Number

State Issued

Check all that apply Check all that apply Valid Expired Suspended Never Applied

What is your trade or profession if any?

Last place of employment & date:

Please describe your current living arrangements:

What is your addiction?

How many years have you been addicted?

Do you believe you have a serious problem?

Have you ever stopped using drugs for any amount of time? Have you ever stopped using drugs for any amount of time? Yes No

If yes, please explain how you did this and how long you stayed off drugs:

List all convictions/arrests:

Do you have any pending court dates and where?

Have you ever been in a correctional facility, state prison, or any other rehab or treatment?

Have you ever experienced or do you presently have any health problems or ever been diagnosed with any mental illness that would keep you from manual work-related activities while enrolled in New Hope Refuge?

Have you ever been diagnosed with HIV or Hepatitis B or C?

Are you currently taking any prescribed medication? Are you currently taking any prescribed medication? Yes No

If yes, please list the name AND dosage of the drug, explain the diagnosis, and length of time you have been taking them:

Do you have at least 7 months of refills on your prescriptions? Do you have at least 7 months of refills on your prescriptions? Yes No

If accepted who will be responsible for paying for doctor visits, medications, and getting your prescriptions refilled?

List the names and ages of your children, current relationship, and where they reside:

Are you currently pregnant?

Marital Status: Marital Status:SingleMarriedSeparatedDivorcedWidowed

Current Spouse (full name)

If in a relationship, please list name and how long you have been together:

Have you struggled with homosexuality? Have you struggled with homosexuality? Yes No

If yes, please explain