Application Please, give us the opportunity to make a positive admissions decision by answering all questions thoroughly and completely. NOTE: Applications that are not thorough and complete will be rejected.If required field does not apply enter NA. First Name(required)Middle Name(required)Last Name(required)Date of Birth(required)Generational SuffixAddress(required)City(required)State(required)AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingZip code(required)Phone Number(required)Email Address(required)Marital status:(required)SingleSeparatedDivorcedWidowedAre you:(required)An AlcoholicChemically DependantOtherWhat drugs have used in the past 3 years?(required)Have you been through a rehabilitation facility? (required)YesNoWhat Rehab have you been to and where is it located?(required)Date of last drink or drug?Have you ever attended AA (Alcoholics Anonymous) or NA (Narcotics Anonymous)?(required)YesNoWhen did you attend your first AA or NA meeting?How many meetings do you attend per week?SelectLess than oneOneTwoThreeFourFiveSixSevenMore than sevenDo you currently take or need prescription drugs?(required)YesNoExplain in DETAIL what prescription drugs you take and why.(required)Do you have any current medical conditions or needs?(required)YesNoList medical conditions requiring special attention.Give a COMPLETE history of your chemical dependency.(required)In DETAIL describe your current situation and reason for seeking help.(required)Reminder: We will keep confidential and not release the following financial and employment information.Are you currently employed?(required)YesNoList your current employer. (required)What and how much is your current source of income?(required)Have you ever been arrested?(required)YesNoGive a DETAILED explanation of all arrests.Do you have a court case pending?(required)YesNoCourt DateWhat is/are the charge(s)?(required)How many times have you been arrested?(required)1234567891011121314151617181920More than 20What was/were the charge(s)?(required)Have you ever been convicted of a misdemeanor? (required)YesNoExplain in detail the misdemeanor conviction(s):(required)Have you ever been convicted of a felony? (required)YesNoExplain in deatail the felony conviction(s):(required)Are you on probation?(required)YesNoPlease list why you’re on probation and your probation officer's name, county and phone number:(required)Are you on parole? (required)YesNoPlease list why you’re on parole and your parole officer's name, county and phone number:(required)Are your probation/parole fines and fees current?(required)YesNoHow much are your fines and fees?(required)Do you have any warrants for your arrest outstanding? (required)YesNoExplain outstanding arrests:(required)Have you ever been arrested or convicted as a sex offender? (required)YesNoExplain sex offender arrest or conviction:(required)Reminder: We will not release and keep confidential the fore going statements. I have read the item above and by typing the LAST FOUR DIGITS of my Social Security Number on this page I understand it is considered a digital signature and understand that if accepted in HAVEN HOUSE, I agree and subject myself to all rules and regulations both present and future including the waiver of any landlord-tenant rights I might have as respect to residency in HAVEN HOUSE. The nature of HAVEN HOUSE requires expulsion, without notice or refund, of any resident who is found to be using either alcohol, drugs or both. IF ACCEPTED YOUR SIGNATURE WILL BE REQUIRED AGAIN UPON ARRIVAL!ENTER THE LAST FOUR DIGITS OF YOUR SSN(required)SendThis field should be left blank
