First Name *

Last Name *

Email Address *

Phone Number *

Is it ok to leave you a voicemail identifying TCC? *

Address Line 1 *

Address Line 2

City *

State *

Zip Code *

Do you have a valid Driver's License? *

Date of Birth *

Race/Ethnicity

Language of choice

Marital Status *

Professional Skills *

Name of Father Confessor *

Phone Number of Father Confessor *

Email of Father Confessor

Name of Sponsor (responsible for monthly payment) *

Phone Number of Sponsor *

Email of Sponsor *

Sponsor's relationship to you *

What addictions are you currently struggling with? *

Date of latest use: *

Are you physically able to take care of yourself? *

Are you currently receiving EBT (food stamps) benefits? *

Have you ever visited TCC? *

Are you capable of comprehending a program of recovery? *

Are you willing and capable of committing to a 9-month program of recovery without any interruptions? *

Why do you want to join the program? *

How did you find out about this program? *

Are you a registered sex offender? *

Do you have any pending court dates? *

Are you on probation or parole? *

Have you been tested for STDs, Hepatitis? *

List your currently prescribed/over the counter medications. *

Do you have health insurance? *

Name of healthcare provider

Health insurance policy number