Date
MM
DD
YYYY
Name
*
First Name
Last Name
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
(###)
###
####
Is this your personal phone number?
Email
*
Social Security Number
Date of Birth
MM
DD
YYYY
Gender
Are you currently in jail or prison?
If you are currently incarcerated, what is your expected release date?
Date of Last Drink
MM
DD
YYYY
Date of Last Drug Use
MM
DD
YYYY
Primary Substance Used
Other Substances Used?
Method of Use
Check all that apply
Age of First Use
How long is your longest period of sobriety in the past?
List all outpatient drug and alcohol programming/treatment you have participated in: (12-step, drug court, IOP)
Have you previously been in any residential facilities?
If you have been in residential facilities previously, where and when?
Are you currently employed?
If yes, who is your employer?
If you are not employed, when were you last employed?
Are you receiving disability, supplemental income or other non-job related income?
If yes, what is the source of income?
What is your current educational status?
If you didn't finish high school, what was your highest grade completed?
Which of the following do you have in your posess?
Check all that apply
Have you ever been charged or convicted of arson?
Have you ever been charged or convicted of a sexual crime?
Are you a veteran?
Do you have any health conditions that require special medical care?
If yes, please explain.
Do you have a medical doctor?
If yes, what is your doctor's name?
Have you ever attempted suicide?
If yes, when did you attempt suicide?
Have you ever recieved mental health treatment?
If yes, was it inpatient or outpatient care?
Are you currently receiving mental health treatment?
If yes, please provide the treatment provider and phone number.
Do you have a mental health diagnosis?
If yes, what is your diagnosis?
Do you take prescription medication(s)?
If yes, list the drugs and the reason the drug has been prescribed.
Do you have any court cases pending?
If yes, explain and list court/division and attorney for each pending case.
Are you currently on probation or parole?
If yes, what is your Officers name and County?
Do you have any outstanding warrants for your arrest?
Are you pregnant?
If yes, when is your due date?
Current Relationship Status
What is your partner's name?
Is your partner in active use?
Do you have children?
If yes, how many children do you have, and what are their ages?
Who are your children currently living with?
I have read all the material on this application and the house rules and I am aware of the conditions of residency at Phoenix House.
Yes
No
I agree to allow the staff of the Phoenix House Program to discuss my background and treatment with other professionals and agencies.
Yes
No
I understand for the protection of myself and others there may be a need for the Board of Directors or the staff of the Phoenix House to check on my legal standing and criminal background. I also understand that I am giving permission for the staff of Phoenix House to contact any and/or all names and facilities on this application.
Yes
No
I have read all the questions and answered them honestly.
Yes
No
I agree to not use non-prescribed drugs, consume alcohol, or violate the law while living at Phoenix House.
Yes
No
I agree to stay current on my weekly house fees, to maintain gainful employment, to attend all required classes, groups, religious services, house meetings and to complete all chores that I am assigned.
Yes
No
Having read through and agreed to everything, please fill out your full name along with the date of the completed application.
