Admission Application

General Information

Social Security Number (Optional)
* Name
* Gender
* Date of Birth

Personal Information

* Address
* City
* Country
* State/Province
* Zip
* E-mail Address
* Primary Telephone Number
* Preferred communication method

Admissions Application

Marital Status
Do you own a car?
Car Make:
Car Model:
Car Year:
Tag #:
Current Employer
Employer Phone
Do you have legal charges pending or a conviction?
If yes, what is the charge?
Which court is hearing the case?
Are you currently on probation?
If yes what is the charge?
State and County?
Are you a Registered Sex Offender?
History of violence toward self, others, or property?
If you answered yes to any of the above legal questions, please explain:
Are you experiencing any medical problems?
Allergies:
Diagnosed with a seizure disorder?
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