Promise of Hope Application
Email address *
Gender *
First Name *
Your answer
Last Name *
Your answer
Address Line 1 *
Your answer
Address Line 2
Your answer
City *
Your answer
State *
ZIP Code *
Your answer
Age *
Your answer
Birthday *
MM
/
DD
/
YYYY
Primary Contact Phone Number *
Your answer
Marital Status
If divorced or separated, list date of
MM
/
DD
/
YYYY
Spouse's Name
Your answer
Number of dependent children
Your answer
Church Affiliation
Your answer
Pastor's Name
Your answer
Church Phone Number
Your answer
Level of Education
Emergency Contact Information
Name of Contact
Your answer
Relationship to Applicant
Your answer
Phone number of emergency contact
Your answer
Personal Medical Status
What type of drugs have you been abusing and how long (Be Complete about frequency and rate)?
Your answer
Is there a history of substance abuse in your family? If so, please describe:
Your answer
Is there a history of violence in your family? If so, please describe:
Your answer
Have you ever had convulsions, seizures, or blackouts? If so, please describe:
Your answer
Any known Allergies? If so, please describe:
Your answer
Other Medical Problems? If so, please describe:
Your answer
Are you taking any perscription medications? If so, please describe:
Your answer
Rate yourself in the following: (Excellent, Good, Fair, Poor)
Physical Condition:
Mental Condition:
Emotional Condition:
Spiritual Condition:
LEGAL STATUS
Are you currently on parole, probation, under bond, or involved in any legal matters at this time? If so, please describe for what and how long:
Your answer
Parole Officer Name:
Your answer
Parole Officer Phone:
Your answer
Who recommended Promise of Hope to you:
Your answer
Have you attended a previous substance abuse program?
Your answer
Comments or Other Important Information:
Your answer
Letter of Motivation:
In filling out an application for entry into Promise of Hope, we ask that you write a letter of motivation, stating why you feel as though you want help at this time in the space provided below. Without letter of motivation your application will not be reviewed. *
Your answer
A copy of your responses will be emailed to the address you provided.
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