Date Of Birth *
Phone Number *
Permanent Address *
Who Is The Best Person To Contact About This Application (Including phone number and/or email address)? *
Are You An Alcoholic? *
Date Of Last Drink? *
Are You Addicted To Drugs? *
Date Of Last Drug Use? *
When Did You Attend Your First AA or NA meeting? *
How Many AA/ NA Meeting Do You Now Attend Each Week? *
Are You Employed? If So, Who Is Your Employer? *
What Is Your Current Monthly Income? *
Place(s) Of Residence During The Past 2 Years *
Do You Have Medical Insurance? If so, Please Provide Name Of Insurer *
Please Provide Names And Contact Info For The First Reference Who Can Vouch For Your Commitment To Recovery *
Please Provide Names And Contact Info For The Second Reference Who Can Vouch For Your Commitment To Recovery *
Have You Ever Been To A Treatment Facility For Alcoholism Or Drug Addiction? If So, List The Treatment Provider *
Do You Take Prescription Drugs? If Yes, List The Drugs, Dosage, And The Reason The Drug Has Been Prescribed *
Do You Currently Have Any Physical Or Mental Health Issues (Including Depression, ADD, And Anxiety)? If So, Please Describe. *We Reserve The Right To Request A Mental Or Physical Evaluation *
Have You Ever Been Charged Or Convicted Of A Felony? Are You On Probation, Parole, Or Have An Upcoming Court Appearance? If So, Please Describe The Circumstances, Charges, And/ Or The Outcome *
Name Of Last Education Institution Or School Attended *
Do You Have A Drivers License? In What State? *
Are You Married? If So, Name Of Spouse *
Fathers Name, Address, Phone Number, Email Address *
Mothers Name, Address, Phone Number, Email Address *
Emergency Contact – Name, Relation, Phone, E-mail *
Back-up Emergency Contact – Name, Relation, Phone, E-mail *
What Are Your Short Term Goals? *
What Are Your Long Term Goals? *
Why Do You Think Residing At Mikes Place Could Help You? *
What Other Information Is Relevant To This Application? *
