Program Application

Your Full name

Your email

Date of Birth

Phone Number:

Is this a cell phone?
YesNo

Anticipated move in date:

Location of interest: BrainerdNorthfield

Are you in a treatment program? YesNo

If applicable, name of the treatment center, institution or facility released from:

A release of information with the above facility must be signed by you, has this been completed?
YesNo

Chemical Use

Sober Date:

Longest continuous period of clean/sober:

Drug of Choice:

List of drugs used in the past 12 months:

Can you pass a drug test today? YesNo

Financial

Are you capable of paying program fees? YesNo

Will you need housing support to help pay for program fees? YesNo

Currently employed? YesNo

Capable of Working/Volunteering? YesNo

Legal

Check one: NoneProbationParolePre-Trial

If so, which state & county?

Agent Name:

Agent Phone:

Criminal Sexual Conduct Convictions? YesNo
(We will do a background check.)

Physical & Mental Health

Are you under the care of a physician? YesNo

Under the care of: PsychologistPsychiatristTherapist

Is this care court ordered? YesNo

Diagnosis:

Prescribed Medications:
(We do not pass medications at our facility. We do offer medication reminders for those needing supplemental services.)

Emergency Contact

Name:

Relationship:

Phone:

How did you find us?

Once this application is submitted, we will reach out to you via phone and email to go over our program guidelines, rules and to sign agreements if approved.