Residential Application-summitoffortpayne

First Name

Last Name

Date of Birth?

Address

Phone Number

Status

Single

Engaged

Married

Divorced

How did you hear about us?

Family

Friends

The Addicition Connection

Website

Do You Have Children

Yes

Please List Names and Ages of Children

Who is taking care of your child(ren)

Have you ever been engaged in homosexual activities?

Yes

If yes, how recently?

Have you been in any treatment/recovery programs?

Yes

If yes, where?

How long did you attend and did you complete?

What types of life controlling problems are you having and why do you feel you need to come to The Summit?

What drugs/alcohol have you used in the last 2 years

When was the last time you used drugs and/or alcohol and what did you use?

What would you say led you to using drugs/alcohol?

What do you think this program can do for you?

Describe your current living conditions.

Are you currently incarcerated? Is so, where?

On Parole/On Probation/Out on Bail?

Please give the name of your Parole Officer, Probation Office or Bail Bondsman

Do you have any pending court cases?

Please list pending cases, State and County cases are in and Attorney for those cases.

Do you have any outstanding warrants? Is so, what State and County?

Have you had any Sexual or Violent Crimes?

MEDICAL

List all important present or past illnesses, injuries or handicaps:

Date of your last medical examination?

Are you on any medications at this time?

Yes

If Yes, please explain and list current medications

Have you ever seen a psychiatrist?

Yes

If so, what was your diagnosis?

Have you ever taken psychiatric medications?

Yes

If yes, please list medications taken.

IF YOU ARE ON MOOD ENHANCING ANTI-DEPRESSANTS, ANTI-ANXIETY, OR NARCOTIC MEDICATIONS, YOU WILL NOT BE ALLOWED TO TAKE THESE IN OUR PROGRAM. PLEASE SEEK DOCTOR'S CARE IF YOU ARE INTERESTED IN COMING OFF UNAPPROVED MEDICATIONS TO BE COMPLIANT FOR OUR PROGRAM. WE DO NOT HAVE MEDICAL PERSONNEL ON STAFF.

Any Physical Disorder/Disease/Physical Limitations

Yes

If so, please explain.

Have you ever attempted to commit suicide?

Yes

If so, please explain.

Have you ever had an eating disorder?

Yes

Self mutilation?

Yes

FINANCE

WORK/EDUCATION

Please give your work history, special trade or skills.

What is your education level?

High School Diploma

College

GED

None

Applicant's Financial Responsibilities

1. Physical examination, including blood test, before entrance into The Summit (required). 2. Accept responsibility for payment of any of the following: Medical and dental bills, medication, eye examination, glasses, clothing, etc.

If you have a family member who has the ability to help offset the cost of your stay while in the program, we ask that you ask them if they would be willing to help by committing to a montly tax-deductible contribution supporting you while in this program. We are a faith-based program and do not receive state or federal funds.

Applicant's Signature

Date

Staff Signature and Date