Please answer all questions honestly. Your responses will not disqualify you for admission.
Name:
Date of Birth
Address
City
State
Zip
Phone
Do you have a valid drivers license? Yes
No
Are you married? Yes
No
Are you a US citizen? Yes
No
What is your drug of choice?
How long have you used drugs?
Have you tried other treatment programs? Yes
No
Have you ever been convicted of a DUI? Yes
No
Have you ever been incarcerated? Yes
No
Are you currently on Welfare, If not have you ever been denied welfare?
What medications are you currently taking if any?
What are you allergic to if anything?
Do you smoke cigarettes? If so how much?
Have you ever attempted suicide? Yes
No
Are you heterosexual? Yes
No
Do you have any physical restrictions? If yes, please explain.
Have you ever been convicted of a sexual related crime? Yes
No
What is your legal situation, if any?
Why do you want to come to Habilitat?
Email Address: