Today's Date
*
-month-
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
-day-
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
-year-
2008
First Name
*
Last Name
*
Age
*
- select -
0 - 5
6 - 11
12 - 14
15 - 18
19 - 24
25 - 34
35 - 44
45 - 54
55 - 64
65 or older
Street Address
*
City
*
State
*
- select -
Alabama
Alaska
American Samoa
Arizona
Arkansas
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
United States Minor Outlying Islands
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Postal Code
*
Primary Phone
*
Alternate Phone
Emergency Contact Person
*
Emergency Phone
*
Relation to You
*
Refer From
Identifying Information
Gender
*
Female Male
Race / Ethnicity
*
- select -
African American
Asian/Pacific Islander
Latino
Native American
Caucasian
Haitian
Cape Verdean
African American and Caucasian
Asian and Caucasian
Native American and Caucasian
Native American and African American
Native Country
- select -
United States
Native Language
- select -
Amharic
Arabic
Armenian
Bosnian
Chinese - Cantonese
Chinese - Mandarin
English
French
French Creole
German
Greek
Gujarathi
Hebrew
Hindi
Miao (Hmong)
Hocano
Hungarian
Italian
Japanese
Korean
Laotian
Mon-Khmer (Cambodian)
Navajo
Persian (including Dari)
Polish
Portuguese
Punjabi
Russian
Samoan
Serbo-Croatian
Somali
Spanish
Tagalog
Thai
Urdu
Vietnamese
Yiddish
Other
Have a valid driver's license
or identification
*
Yes No
Citizenship Information
*
Family History
Marital Status
*
- select -
Single
Married
Domestic Partner
Widowed
Separated
Divorced
Do you have any children
under your custody?
*
Yes No
Education History
Education
*
- select -
No grade school
1 year of school
2 years of school
3 years of school
4 years of school
5 years of school
6 years of school
7 years of school
8 years of school
9 years of school
10 years of school
11 years of school
Completed 12 years of school but no HS diploma
High school diploma
GED or certificate of equivalency for HS
1 years of college completed
2 years of college completed
3 years of college completed
BA/BS or equivalent
Education beyond a bachelor's degree
Master's degree
Doctoral degree
Vocational/technical degree
Associate's degree
Military History
Have you ever served in
the Arms Forces?
*
Yes No
Medical History
Do you have any medical conditions
that may interfere with you giving
100% participation to the program?
*
Yes No
Addiction History
Are you currently being challenged
with any addiction issues?
*
Yes No
Are you now or have you ever been
enrolled in a Recovery/Rehabilitation
Program?
*
Yes No
Answer the following questions if you are or have ever been enrolled in
a Recovery/Rehabilitation Program
Recovery/Rehabilitation Program
Location of the Program
Duration in the Program
Legal/Criminal History
Have you ever been arrested, charged,
convicted, or plead guilty
to any crime?
*
Yes No
Are you currently on probation?
*
Yes No
Answer the following two questions if you are currently on probation
Probation Officer's Name
Probation Officer's Phone
Are you currently on parole?
*
Yes No
Income Sources
Financial Assistance
*
Work History
Are you currently employed?
*
Yes No
If you are currently employed:
Employment Status
Full Time Part Time
More About You
What is your career objective?
Two things you would like to accomplish in this program that will contribute to you meeting your career objective?
Type of employment interests you most and why?
List three of your personal strengths
List three things that you want to improve
If we could support you in only one area you want to improve, what would that area be and why?