Do you have any allergies? Yes No If yes, list allergies: Have you ever been treated for substance Do you attend NA/AA meetings? abuse? Yes No Yes No List treatment providers and approx. dates: is your home group? Your sponsors name: Phone number: How old were you when you started using? Date you last used? What is your drug of choice? What have you used? What quantity did you use? How often did you use? Financial Information Income Sources/ Amount: Employment Income Food Stamps General Public Assistance (TDAP) Pension Supplemental Social Security Income (SSI) Veterans Benefits Social Security Disability Insurance (SSDI) Unemployment Benefits Social Security (Retirement) No Financial Resources Other: Total Amount received? $ Employment Information Current Employer: Last Employer: Company: Company: Job Title: Job Title: Start Date: Start Date: End Date: End Date: Hourly Pay: Hourly Pay:
Do you have any allergies? Yes No If yes, list allergies: Have you ever been treated for substance abuse? Yes No List treatment providers and approx. dates: Do you attend NA/AA meetings? Yes No is your home group? Your sponsors name: Phone number: How old were you when you started using? Date you last used? What is your drug of choice? What have you used? How often did you use? What quantity did you use? Financial Information Income Sources/ Amount: Employment Income Food Stamps General Public Assistance (TDAP) Pension Supplemental Social Security Income (SSI) Veterans Benefits Social Security Disability Insurance (SSDI) Unemployment Benefits Social Security (Retirement) No Financial Resources Other: Total Amount received? $ Employment Information Current Employer: Company: Job Title: Start Date: End Date: Hourly Pay: Last Employer: Company: Job Title: Start Date: End Date: Hourly Pay:
NewApplicationEarlsPlaceWebsite_2018.docx