Admissions
All potential residents must fill out this form and submit it. Submitting this application is not a guarantee of admission.
First Name *
Middle Name
Last Name *
Street Address 1 *
Street Address 2
City *
State *
Zip Code *
Age *
Email Address *
Your Phone Number (cell)
Emergency Contact Name *
Emergency Contact Phone *
Emergency Contact Relationship\ *
Drug & Alcohol History *
Required
Date of Last Use *
MM
/
DD
/
YYYY
If you are in treatment now, what is the name of the treatment facility?
Name of Counselor
Counselor's Phone or Email Address
Expected Discharge Date
MM
/
DD
/
YYYY
Are you scheduled to attend PHP or IOP *
If you are scheduled for PHP or IOP, where?
Previous Treatment Centers
Previous Sober Living/Recovery House Arrangements
Check Any / All That Apply *
Required
If you checked any of the above, please explain in more detail
Do you have medical insurance *
Insurance Provider
If you take prescription medication(s), list medications
Allergies & Medical Conditions
Allergies and Medical Conditions (Please list anything you are allergic to along with what happens if you are exposed to it (e.g. Peanuts - break out in hives) as well as any medical conditions you may have (Bipolar Disorder, Carpal Tunnel Syndrome, etc) putting each allergy/condition on a separate line. If you do not have any allergies or medical conditions apart from your addiction, put "none")
Are you currently employed *
If not, are you able to work
Clear selection
If you are unable to work, please explain why
Employer's Name
Supervisor's Name
How Many Hours Do You Work a Week?
Work Schedule
I agree to these Terms and Conditions - By selecting the checkbox below and typing my name, I hereby certify that the information above is true and accurate and that "BridgeWay House" may utilize the information I provided in rendering a decision on my acceptance into the sober living program they facilitate as well as to run a background check and schedule a pre-acceptance interview with me. *
Required
Please Write Out Your Full Name - By writing your full name, you accept and agree to the above statement. *
Submit
Never submit passwords through Google Forms.
This form was created inside of BridgeWay House Inc..