Her Story Application
Please fill out the information requested below and we will get back to you within 24 hrs.
Email address *
Name *
First and last name
Your answer
Address (most recent) *
Your answer
Phone number *
Your answer
Is this application for: *
If you are applying on behalf of someone else, please explain your relationship and whether or not she is willing to get help.
Your answer
Are you currently employed? If yes, where at? *
Your answer
What is your current living situation (homeless, with friends, etc.)? *
Your answer
What substances are you currently using (heroin, cocaine, etc.)? *
Your answer
When was the last time you used? *
Your answer
List past treatment or recovery programs, if any. *
Your answer
Do you currently have a sponsor? *
Your answer
Do you have any Court, Probation or Children's Services cases that are currently open? If yes, what county are your services in? *
Your answer
Do you have any past or current mental health diagnosis? If yes, please provide your diagnosis. *
Your answer
Are you currently on any medications? If yes, please list them. *
Your answer
What do you hope to accomplish by coming to Her Story? *
Your answer
Please share anything else you would like us to know.
Your answer
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This form was created inside of Whitney Caudill. Report Abuse