THRIVE APPLICATION
FOR PARTICIPANTS TO FILL OUT BEFORE INTERVIEW
Thrive aims to see young women and their infants who face challenges related to substance use, embraced, educated, empowered and established as they journey toward holistic health. We cannot always guarantee a space to all who ask - as space is limited - but we do our best to respond to those in need and to help them find their way forward. In order to best care for everyone living within Thrive (including staff who reside in the home), we ask for full disclosure and honesty of those looking to reside here. We also ask that participants contribute to the Thrive environment and join in daily rhythms as they are able. We respect your privacy and information given will be kept confidential.
Name *
Your answer
Date of Application: *
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Date of Birth: *
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Ethnicity/Band: *
Your answer
Phone: *
Your answer
E-mail:
Your answer
Current Address
Your answer
Postal Code:
Your answer
Mailing Address:
Your answer
Postal Code:
Your answer
Emergency Contact Name:
Your answer
Emergency Contact Number:
Your answer
Relationship to Emergency Contact:
Your answer
Are you pregnant? *
If Yes, when is your due date?
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