Name
*
First Name
Last Name
Email
*
Phone
*
(###)
###
####
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Date of Birth
*
MM
DD
YYYY
Marital Status
*
Do you Have Children
*
If yes, How Many?
Do you have custody of your children?
*
If you do not have custody, please list who does & if reunification is a goal at this time?
Names, Ages, Gender of Children:
Education, Highest Grade Completed"
*
Technical School/College:
Certificate "In" / Degree "In" :
Last Places of Employment:
*
Please List Place, Job Title, Dates (Beginning to End):
Please List any Specific Skills/Abilities :
Do you have a Valid Driver's License?
*
Driver's License Number if Available:
Driver's License State:
Expiration Date on License:
MM
DD
YYYY
Chemical Abuse History, Drugs Used:
*
First Age Used?
*
What is your Drug of Choice?
*
Last Date Used (most Recent):
*
MM
DD
YYYY
Average Amount Used?
*
How Often & Method Used?
*
List Facility of Prior Treatment for Addiction
Date Began Treatment (if applicable)
MM
DD
YYYY
Date Treatment Ended (if applicable)
MM
DD
YYYY
Did you Complete the Treatment Program?
Reason for not completing the program (if applicable)?
Please list any mental health disorders you have been diagnosed with (i.e. anxiety, depression, bi-polar, schizophrenia) and when you were diagnosed:
*
If none, type "None"
Are you currently prescribed any medications for a mental health disorder?
*
Please list the name, strength, frequency, and prescribing physician for each medication:
Have you ever had suicidal thoughts?
*
If yes, did you have a plan?
*
Have you attempted suicide?
*
Weight:
Height
Allergies?
*
List all allergies, or if none, mark as "None"
Diabetes
*
Epilepsy or Seizures?
*
Thyroid (high/low)?
Hypertension?
Any Chronic Diseases, illness, or disability that you are currently living with?
*
Are you currently prescribed any medications for a medical condition?
*
If yes, please list the name, strength, frequency, and prescribing physician for each medication:
Have you Experienced any of the following types of Abuse in your lifetime?
If you have experienced abuse, and are able to do so, please briefly describe the circumstances:
Are you currently on probation or parole?
*
If yes, please list county, officer's name, charge, & end of sentence date:
Beginning Date of Current Incarceration
MM
DD
YYYY
End Date of Current Incarceration
MM
DD
YYYY
Location of Current Incarceration
Reason for Current Incarceration
Beginning Date of Prior Incarceration
MM
DD
YYYY
End Date of Prior Incarceration
MM
DD
YYYY
Location of Prior Incarceration
Reason for Prior Incarceration
Do you have pending charges?
*
If pending charges exist, please give a brief description of charges & court date if known:
Are you willing to submit to an alcohol and drug testing upon admission as well as random testing?
*
Are you willing to participate in chores, groups, and Bible studies on a daily basis?
*
Are you willing to work a job when the staff of Restore 6:34 feels you are ready for employment?
*
Signature:
*
Date
MM
DD
YYYY
Name of an Emergency Contact & Relationship
*
Address of Emergency Contact
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Emergency Contact's Phone Number:
*
(###)
###
####
Name of a Personal Reference & Relationship
Address of Personal Reference
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone Number for Personal Reference:
(###)
###
####
Please describe your salvation experience.
*
Please write a personal letter as to why you would like to be approved for admission into the Restore 6:34 program.
*
