Application

Marital Status: *

Single

Married

Divorced

Separated

Widowed

Applicant Address: *

Applicant Phone Number: *

Do you use cigarettes or e-cigarettes (vaping)? *

Yes

No

How long have you been using it? *

If yes, how many times? IF NO, enter N/A *

Are you currently on any medications? *

Yes

No

Answer all questions fully, truthfully, and to the best of your ability. *

By checking this box I acknowledge that all my answers are true and that intentionally falsifying any answers could result in being disqualified and immediately dismissed from the program.

Name and phone number of BEST CONTACT TO GET A HOLD OF APPLICANT: *

Date and time this form filled out *

Have you ever been involved with social services regarding your children? *

Yes

No

Does Not Apply

Weight: *

Date of Birth *

Our program requires physical labor, the ability to lift, work while standing, and the ability to climb stairs, etc. Do you meet these physical requirements? Failure to truthfully disclose your physical abilities and medical conditions can and may result in immediate dismissal from the program. *

Yes

No

Do you have children? *

Yes

No

LEGAL HISTORY: Have you ever been arrested? *

Yes

No

If yes, please enter DATE PROBATION/PAROLE BEGAN, ENDING DATE, PROBATION OFFICER, OFFICER'S PHONE NUMBER, and OFFICER'S ADDRESS. IF NO, enter N/A *

If yes, how many times and on what? Please explain. IF NO, enter N/A *

Date of your last drug or alcohol use: *

Eye Color: *

If yes, please LIST MEDICATION, DOSE, TIMES A DAY, DIAGNOSIS, AND DATE BEGAN. IF NO, enter N/A. *

Do you have any pending charges? *

Yes

No

Number of years you have smoked: (If you do not smoke, enter N/A *

If yes, how many times and where? PLEASE ENTER FACILITY NAME, LENGTH OF PROGRAM, DATE ATTENDED, AND WHETHER OR NOT YOU COMPLETED THE PROGRAM. If you have not been to any treatment programs, enter N/A. *

Have you ever been to Detox? *

Yes

No

I am dedicated to changing my life and seeking a new way of doing things. I have answered the questions fully and truthfully. Please enter your name below to attest to this. *

Are you willing to quit? *

Yes

No

Current Age of Applicant: *

Please enter your arrest history. Include DATE ARRESTED, LIST OF CHARGES, and WHETHER OR NOT YOU WERE CONVICTED. If you have never been arrested, enter N/A. *

If Yes, how many packs or pods a day? *

One

Two

Three or More

I do not smoke

Height: *

Have you ever been diagnosed with a mental health disorder? *

Yes

No

If yes, please list DATE ARRESTED, STATE, LIST OF CHARGES, and COURT DATE. IF NO, enter N/A *

If yes, please describe the disorder and how it impairs your life. IF NO, enter N/A. *

If yes, please list HOW MANY AND THE NAMES AND AGES OF EACH CHILD. IF NO, enter N/A *

Please list all substances including alcohol you are currently addicted to or using or have been addicted to in the past. Please list in order of frequency of use. LIST: DRUG/ALCOHOL NAME, HOW OFTEN USED, AGE BEGAN, DATE OF LAST USE. *

Who will be providing care for your children while they are in the program? List name(s) and contact information. If this does NOT apply, enter N/A *

How would you rate your health? *

Very good

Good

Fair

Poor

If yes, please explain. IF NO, enter N/A *

Have you tested positive for Hepatitis? Testing positive does not disqualify you from the program. *

Yes

No

In treatment, there is no fraternizing with the opposite or same sex. Fraternization is a violation of Sparrow's Nest policy and can and may result in immediate dismissal from the program. Are you able to cooperate with this policy? *

Yes

No

Are you presently on probation or parole? *

Yes

No

Applicant Email Address:

Have you tested positive for HIV? Testing positive does not disqualify you from the program. *

Yes

No

If yes, describe the condition(s) and how it/they impact your life. IF NONE, ENTER N/A *

Do you have a boyfriend or common law spouse? *

Yes

No

Are you listed or required to be listed as a sex offender? *

Yes

No

If yes, I understand this person will not be able to communicate with me in any manner during the course of the program. PLEASE ENTER INITIALS IF YES, If this does NOT apply to you, enter N/A. *

Name of Applicant: *

Hair Color: *

If yes, what for? IF NO, ENTER N/A *

I understand that any undisclosed medical issues that are discovered after admission could place my stay and treatment at Sparrow's Nest in jeopardy. *

What did you use? *

Have you ever overdosed? *

Yes

No