Admission Application
General Information
* Name
* Gender
Agender
Demi-queer
Female
Genderqueer
Male
Non-binary
Other
Trans Femme
Trans Man
Trans Masculine
Trans Woman
Transgender
Two-Spirit
* Date of Birth
Social Security Number (Optional)
Personal Information
* Address
* City
* Country
Canada
New Zealand
United Kingdom
United States of America
* State/Province
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Nova Scotia
Ontario
Prince Edward Island
Quebec
Saskatchewan
* Zip
* E-mail Address
* Primary Telephone Number
* Preferred communication method
SMS
Email
Both
Neither
Portal Access
* Username
* Temporary Password
Admissions Application
Marital Status
Do you own a car?
Yes
No
Car Make:
Car Model:
Car Year:
Tag #:
Current Employer
Employer Phone
Do you have legal charges pending or a conviction?
Yes
No
If yes, what is the charge?
Which court is hearing the case?
Are you currently on probation?
Yes
No
If yes what is the charge?
State and County?
Are you a Registered Sex Offender?
Yes
No
History of violence toward self, others, or property?
Yes
No
If you answered yes to any of the above legal questions, please explain:
Are you experiencing any medical problems?
Yes
No
Allergies:
Yes
No
Diagnosed with a seizure disorder?
Yes
No
Please describe any medical issues marked "yes":
Medications (List all current medications prescribed, non-prescribed, or any over the counter):
List all mental health hospitalizations in the past 3 years:
What are your substance(s) of choice?
How long have you been clean and sober from using alcohol and/or other drugs?
Describe your current living situation:
Explain reasons for wanting to live in The Evolution House:
Describe your current recovery goals:
Describe what you have done for your recovery that has been successful:
Describe what you have done for your recovery that has NOT been successful:
What are the best ways The Evolution House can support you in establishing long-term recovery?
How did you hear about The Evolution House?
Admissions Application - Emergency Contacts
Emergency Contact Name
Phone
Relation
Emergency Contact Name
Phone
Relation
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