Resident Application Form

Please fill out all sections truthfully. Your information is confidential.

General Information

First Name

M.I.

Last Name

Street

City

State

Zip

Cell #

Alt #

S.S. #

Driver License/State ID #

Birth Date

Ethnic Background

Current Status

Married

Single

Divorced

Separated

Emergency Contact Information

Name

Relation

Tel

Name (Second)

Relation

Tel

Status (Probation, DHS Involved, Court Involved, etc.)

PO, DHSCW, etc. Name

Phone #

Military or Veteran?

Yes

Branch

Referred By

Substance Abuse History

List your substance(s) or \"drug(s)\" of choice

Are you on any of the above substance(s) now?

Yes

If yes, please list which ones

If no, what was the date of last Use

List Prior Sober Living Homes and Include Date and Length of Stay For Each

How old were you when you first used alcohol and drugs?

Have you ever been in a Drug/Alcohol Treatment Center?

Yes

If so, where?

Have you ever resided in a halfway house?

Yes

If so, where?

Have you ever been convicted and/or arrested of a crime?

Yes

If yes, please list and describe each

Background and Health

Have you ever been in prison/incarcerated?

Yes

If yes, please list and describe each

Have you ever been ARRESTED AND/OR CONVICTED of a sex related crime/offense?

Yes

If yes, please describe

Where and with whom do you currently reside?

Have you been diagnosed with any mental condition(s)/disorder(s)?

Yes

If yes, please list each and indicate any treatment (i.e., counseling)

Have you ever attempted suicide?

Yes

If yes, how long ago

Did you seek counseling or other help at that time?

Yes

How did you hear about us?

Employment

Are you currently employed?

Yes

If yes, where do you work?

How much is your income after taxes (net)?

Do you get paid

Weekly

Bi-weekly

Monthly

Do you have any other sources of income?

Yes

If yes, from where?

What is your current means of transportation?

Other

Are you prejudiced towards any ethnic group or race?

Yes

If yes, please explain

By checking the box, you are giving us permission to bill your insurance for any services while you are a participant at SuPEErior Connections.

Disclaimer: By submitting, I am stating that my answers to the above questions have been truthful and accurate to the best of my knowledge. I understand that deliberately making false statements and responses to any of the above questions may result in immediate eviction from the premises. We require honesty, a core principle, vital to maintaining a healthy and sober life.

Print Name

Date

Signature (type your name)