Priority House

Where Responsibility For Personal Recovery Comes First

                                                               PRIORITY HOUSE APPLICATION    

LAST NAME                                           FIRST                                            MIDDLE                                                  


TODAYS DATE            /              /             SS#                   -                  -                   DATE OF BIRTH            /            /           


GENDER [ ]MALE [ ]FEMALE [ ]OTHER RACE_____________ HEIGHT__________ WEIGHT_________


ARE YOU AN ALCOHOLIC AND/OR A DRUG ADDICT? [ ]YES [ ]NO


PLEASE CHECK ALL OF THE FOLLOWING FORMS OF ID WHICH YOU HAVE IN YOUR

POSSESSION: PICTURE I.D REQUIRED


[  ] BIRTH CERTIFICATE [  ] DRIVERS LICENSE [  ] SS CARD [  ] STATE PICTURE ID


ARE YOU CURRENTLY IN TREATMENT? [  ]YES [  ]NO


IF YES, WHERE?                                                            COUNSELOR’S NAME                                                           


CHECK ONE [  ]INPATIENT [  ]OUTPATIENT [  ]INTENSIVE OUTPATIENT


ADMISSION DATE            /           /          DISCHARGE DATE            /          /           


IF YOU ARE NOT IN TREATMENT, WHERE ARE YOU STAYING NOW? 


PHONE NUMBER                              PERSON TO ASK FOR IF YOU ARE NOT AVAILABLE________________________________ IF


INCARCERATED, WHAT IS YOUR EARLIEST PROJECTED RELEASE DATE? ________________________________________________________


WHEN WAS YOUR LAST DRINK AND/OR DRUG? _______________________________________________


WHAT IS YOUR DRUG OF CHOICE?___________________________________________________________


ARE BOTH YOUR PARENTS LIVING? [  ]YES [  ]NO ARE THEY STILL MARRIED? [  ] YES [  ]NO


WHAT ARE THEIR OCCUPATIONS? MOTHER                                           FATHER                                          


HAVE YOU BEEN DIAGNOSED WITH ANY PSYCHOLOGICAL DISORDERS OTHER THAN

ALCOHOL AND DRUG DEPENDENCY INCLUDING MAJOR DEPRESSION, BI POLAR,

SCHIZOPHRENIA,PARANOIA, BORDER LINE PERSONALITY, ETC.? [  ]YES [  ]NO


IF YES, LIST EACH ONE_______________________________________________________________________________________________________________________________________________


DO YOU HAVE ANY PHYSICAL HEALTH PROBLEMS INCLUDING HERNIA, HEPATITIS B,

HEPATITIS C,HIV VIRUS, BACK PROBLEMS, OR OTHER LIMITATIONS? [  ]YES [  ]NO


IF YES, LIST EACH ONE________________________________________________________________________________________________________________________________________________


ARE YOU CURRENTLY ON ANY MEDICATION? [  ]YES [  ]NO


IF YES, LIST ALL TYPES: ______________________________________________________________________________________________________________________________________________


ARE YOU CURRENTLY RECEIVING SSI OR DISABILITY INCOME? [  ]YES [  ]NO


IF YES, WHY ARE YOU RECEIVING IT?                                                                                                


WHAT IS THE MONTHLY AMOUNT? $                                                                                                 


HAVE YOU EVER BEEN CHARGED OR CONVICTED OF ANY SEX CRIME? [  ] YES [  ] NO. IF YES


PLEASE EXPLAIN        _______________________________________________________________________________________________________________________________________________


LIST EVERYTHING THAT YOU HAVE EVER BEEN ARRESTED FOR .

                                                                                                                                                                                                 


DO YOU HAVE ANY LEGAL CHARGES PENDING NOW? [  ]YES [  ]NO


IF YES, LIST COURT DATE(S)                                                                                                                                                


LIST CHARGE(S)                                                                                                                                                                            


ARE YOU CURRENTLY ON PROBATION? [  ]YES [  ]NO


IF YES, NAME OF P.O.                                                                 P.O. PHONE #                                                              


ARE YOU COURT ORDERED TO LIVE IN A HALF WAY HOUSE? [  ]YES [  ]NO


DO YOU HAVE $100 ADMISSION FEE P LUS FIRST WEEKS RENT$140[  ]YES [  ]NO


DO YOU UNDERSTAND THAT THERE ARE NO REFUNDS IF YOU ARE NON-COMPLIANT OR IF

YOU LEAVE AGAINST  ADVICE ? [  ]YES [  ]NO 


DO YOU HAVE VERIFIABLE EMPLOYMENT? [  ]YES [  ]NO


IF NOT EMPLOYED OR IF YOU BECOME UNEMPLOYED ARE YOU WILLING TO TAKE ANY JOB AVAILABLE? [  ]YES [  ]NO


ARE YOU IN A RELATIONSHIP? [  ]YES [  ]NO IF YES, HOW LONG? ______________________________


PERSONS NAME?                                                                                                     IS IT YOUR SPOUSE? [  ]YES [  ]NO


ARE YOU WILLING TO COMMIT YOURSELF TO THE TWELVE STEP PROGRAMS WAY OF LIFE ?

 [ ]YES[ ]NO


ARE YOU WILLING TO FOLLOW ALL OF THE SUGGESTIONS AT PRIORITY HOUSE? [  ]YES [  ]NO


EMERGENCY CONTACT: RELATIONSHIP                                                     PHONE#                                                          

 

USE ADDITIONAL PAPER IF NESSECARY