Contact | GRACE House

Resident Information

Please provide the information requested below.

First Name *

Last Name *

Date of Application *

Date of Birth *

Age *0 / 3

Sobriety Date

Home Address *

City *

County

Social Security Number *Use the format 000-00-0000.0 / 11

Marital Status *SingleMarriedDivorced

Cash on Hand

Physical Difficulties

Special Accommodations Needed

Treatment, Recovery & Health

Treatment FacilitiesAdd each treatment facility and the dates attended, if applicable.

Treatment Facility *

Dates (From / To) *

Add Treatment Facility Remove

Do you consider yourself an alcoholic? *YesNo

Do you consider yourself an addict? *YesNo

Are you dependent on any type of drug? *YesNo

Are you presently taking medication prescribed by a physician? *YesNo

What drug or drugs? *

Medications, Vitamins, Herbs & SupplementsList anything you currently take, whether prescribed or not.

Medication or Supplement *

Add Medication or Supplement Remove

Other Diagnosis *

Year(s) Diagnosed

Do you see a therapist regularly? *YesNo

Do you see a psychiatrist regularly? *YesNo

Therapist Name *

Psychiatrist Name *

Are you willing to accept any type of employment? *YesNo

Recovery Support & Legal Information

Do you have AA contacts? *YesNo

Do you have an AA sponsor? *YesNo

If Yes: Who, Where and When? *

Sponsor Name *

Sponsor Phone *

Are you on probation or parole? *YesNo

If Yes: Where? *

Lawyer

Lawyer Phone

Probation / Parole Officer *

Officer Phone *

Emergency Contact & Signature

Person to Notify in Case of an Emergency *

Emergency Contact Phone *

Relationship *

Your Signature *Typing your name here serves as your electronic signature.

Your Phone *

Date *

How can we help?

Resident Information

Please provide the information requested below.

Treatment, Recovery & Health

Recovery Support & Legal Information

Emergency Contact & Signature