Men’s Addiction Support

Full Name *

First Name

Last Name

Current Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Date of Birth *

MM

DD

YYYY

Gender *

Male

Female

Are you a U.S. Citizen? *

Yes

No

Marital Status *

Single

Engaged

Divorced

Married

Separated

Do you have friends or relatives in this program? *

Yes

No

Medical History (Check all that apply to your current and past conditions). *

Alcohol Abuse

Asthma

Back Problems

Broken Bones/Sprains

Diabetes

Drug Abuse

Head Trauma/TBI

Heart Condition

Hepatitis

High Blood Pressure

HIV/AIDS

Migraines

Respiratory Problems

Seizures

STI/STD

Tuberculosis

Other

Are you currently being treated by a doctor? *

Yes

No

Are you allergic to any medications? *

Yes

No

Are you currently being treated with prescribed narcotics? *

Yes

No

Are you currently prescribed any non-psychiatric medications? *

Yes

No

Have you ever been treated for mental disorders? *

Yes

No

Have you ever been treated by a Psychiatrist/Psychologist? *

Yes

No

Are you currently prescribed any psychiatric medications? *

Yes

No

Have you thought about or attempted suicide in the past six months? *

Yes

No

Are you currently on probation? *

Yes

No

Are you currently on parole? *

Yes

No

Do you currently have any court cases pending? *

Yes

No

Are you currently under investigation? *

Yes

No

Do you have any outstanding warrants for your arrest? *

Yes

No

Have you ever been convicted of a violent crime? *

Yes

No

Are you currently facing charges for a violent or sex-related crime? *

Yes

No

Are you required to register as a sexual or predatory offender? *

Yes

No

Do you have an attorney? *

Yes

No

Legal History (Check all that you have been involved with) *

Aiding & Abetting

Attempted Murder

Attempted Robbery

Battery

Credit Card Fraud

Drug Distribution

DUI

DWI

Embesslement

Fraud

Identity Theft

Larceny/Grand Larceny

Manslaughter

Murder

Parole Violation

Prostitution

Sex with a Minor

Shoplifting

Soliciting Prostitution

Other

Emergency Contact Name *

First Name

Last Name

Emergency Contact Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact Phone *

(###)

###

####

Are you currently employed? *

Yes

No

Do you currently receive government assistance? *

Yes

No

I acknowledge and commit to pay the Induction Fee of $750.00. *

Cost of program and/or financial aid will be discussed at induction

Yes

I agree to seek financial help from friends or family

I need financial aid

Please check the following boxes to indicate that you have received, read, and agree to abide by the program guidelines listed below. *

Program Policies and General Information

Room and Board Fee Information

Prohibited Medication

Please type your Electronic Signature Below *

First Name

Last Name

Date *

MM

DD

YYYY