Online Application

Legal Name *

Preferred Name

Date of Birth *

Age *

Race *

Birthplace (City,State) *

Social Security # *

Drivers License Number ( and Expiration Date) *

Street Address *

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Home/Cell *

Work Phone Number

Have you ever applied to Forge Recovery Center in the past? *YesNo

If yes, please give approximate date

Family Information

Do you have any children? *YesNo

If yes, how many?

Names and Ages of Children

Who has custody of your children?

What arrangements are being made for your children while you are at Forge Recovery Center?

Do you receive any type of government assistance? *YesNo

If yes, please explain

Parents

Fathers Name *

Is your father living or deceased *LivingDeceased

Home/ Cell Phone *

Work Phone

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Mothers Name *

Is your mother living or deceased *LivingDeceased

Home/ Cell Phone *

Work Phone

Street Address *

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Do your parents get along? *YesNo

If no, please explain

Do you live with your parents? *YesNo

Describe your relationship with your father: *

Describe your relationship with your mother: *

As a child, did you feel closest to: *FatherMotherSomeone Else

If someone else, please explain:

Siblings

How many brothers do you have? *

How many sisters do you have? *

Do any of your siblings have a history of substance abuse? *YesNo

If yes, please explain:

Education

If less that high school, what was the last grade completed?

Last school attended: *

Dates of attendance: *

Have you ever been in any special education classes? *YesNo

If yes, please list:

Health and Medical History

Name of Primary physician *

Date of last physical examination: *

Do you have any health concerns or physical disabilities that Forge Recovery Center needs to be made aware of? *YesNo

If yes, please describe:

Undisclosed medical issues that are discovered after admission to Forge, Failure to answer any questions truthfully, or withholding of any information may be grounds for dismissal from the program.

Are you currently taking any prescribed medication? *YesNo

If yes, please list the medication, dosage, duration, what it was prescribed for and the Prescribing doctors name and phone number:

Do you have any immediate medical or dental needs? *YesNo

If yes, please describe:

Do you have a history of seizures? *YesNo

If yes, please specify:

Date and type of last seizure:

General diagnosis and description of seizures:

Psychological History

Have you ever tried to commit suicide? *YesNo

If yes, please explain:

Have you had suicidal thoughts and/ or are you currently thinking about suicide? *YesNo

If yes, please explain

And if yes, do you have a plan to commit suicide?YesNo

If yes, please explain

Have you ever thought of killing anyone? *YesNo

If yes, please explain

Have you ever killed anyone? *YesNo

If yes, please explain

Have you ever tried to kill anyone? *YesNo

If yes, please explain

Have you ever tried to harm yourself in any way? *YesNo

If yes, please explain

Have you ever been to a psychiatrist or been committed for a psychological evaluation? *YesNo

If yes, please give details:

Substance Abuse

Drug of choice & Length of Use: *

Habit cost per day? *

Longest period clean? *

Have you ever been in an alcohol, drug or detoxification program? *YesNo

If yes, was it:Faith BasedNon- Faith Based

If yes, give details

Legal History

Have you ever been arrested? *YesNo

If yes, please indicate the number of times you have been charged with the following crimes:

Disorderly Conduct:

Weapons Offense:

Shoplifting:

Burglary, Larceny, B&E:

Drug Charges:

Forgery:

Arson:

Assault:

Robbery:

Theft by Deception:

Sexual Assault:

Rape:

Public Intoxication:

Parole/Probation Violation:

Prostitution:

Homicide, Manslaughter:

DWI:

Other:

Explain further about the crimes you have been charged with: *

Do you have any pending charges? *YesNo

If yes, please give details: ( Date of Arrest/Charge, State Arrested in, Name of Judge, List of Present Charges, Court Date)

Do you have an attorney? *YesNo

If yes, provide: Attorneys Name, Telephone #, Address, City, State

Have you been court ordered to complete treatment? *YesNo

If yes, give details: Date of Sentence, Exact Sentence Stipulation, Name of Judge

Are you currently on probation/Parole? *YesNo

If yes, What are your charges?

Date probation/parole began:

Date probation/ parole scheduled to end:

Current Probation/ Parole Officer Name:

Officers Telephone #

Street Address

City

State/Province

Have you ever been on probation/ parole? *YesNo

If yes, please explain

Why would you like to come to Forge Recovery Center? *

What would you like to see happen in your life while in this program? *

Applicant Signature *