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Priorit​y 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

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