First Name

Last Name

I have been sober for at least 30 days.

I am not on a MAT program with the exception of Vivitrol).

I am not a registered sex offender.

I am at least 21 years of age or older.

I am willing to commit to a 9-18 month program

I have read Reset's Policies.

Email

Phone

Gender: --None-- Female Male Other

Date of Birth:

How did you hear about Reset?:

When would you be able to move in?:

What other programs have you contacted?:

Please list all convictions and dates.:

Terms of parole or probation (if any):

Do you have a significant other?:--None--Yes No

Do you have children?:--None--Yes No

If yes, where do they live now?:

Do you have any sources of income?:

What type of jobs have you done before?:

Have you ever served in the military?:--None--No. Yes - Air Force Yes- Army Yes - Coast Guard Yes - Marines Yes - Navy

If you served, when were you discharged?:

Do you have any legal issues?:--None--Yes No

If you have legal issues, please explain:

Please describe programs/recovery groups:

When did you last use alcohol or drugs?:

Substance type/amount used in last 24 hr:

Have you ever tried to stop before?:

Did you have any medical complications?:--None--Yes No

Please explain any medical complications:

Have you ever been in treatment/detox?:--None--Yes No

If yes, when & where?:

What is your primary drug addiction?:

Date of last use for primary addiction:

What is your secondary drug addiction?:

Date of last use for secondary addiction:

What age were you when you began using?:

Do you have any physical disabilities?:--None--Yes No

If you have disabilities, please explain:

Are you taking any medications?:--None--Yes No

If you are, please explain:

Please tell us your faith background.: