Application

First Name

Last Name

Phone

Date

City of Residencee

SSN

Do you have a valid driver's license?

Driver's License Number (if Applicable)

Do you have transportation?

Vehicle Plate Number

Do you have health insurance?

Do you have accessibility needs?

Highest Level of Education

Emergency Contact Information

Are you in Court, or on Probation / Parole?

Parole / Probation Officers Name and Phone Number

Military Service?

Family?

Are you currently receiving any treatment for substance abuse disorder?

Are you on medication assisted treatment?

Do you need treatment transportation assistance?

Do you want us to play a role in your treatment?

Have you been diagnosed with a Mental Illness?

If yes, are you on any medications?

What was the diagnoses?

Any Health Issues we need to be aware of?

Are you on any medication for non mental health related issues?

Medication Name(s)

Employed?

Employer Name

Hours worked?

Do you need employment assistance?

Is your Family Relationship in good standing?

Short Term or Long Term Goals?

What helps you stay sober?

How do you feel about sharing living space with other individuals

What are your expectations from All In Recovery?

What would you like assistance from the All In Recovery House Staff?

I HAVE READ ALL OF THE HOUSE RULES?

I AGREE TO COMPLY WITH ALL RULES?