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
Address (most recent) *
Phone number *
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.
Are you currently employed? If yes, where at? *
What is your current living situation (homeless, with friends, etc.)? *
What substances are you currently using (heroin, cocaine, etc.)? *
When was the last time you used? *
List past treatment or recovery programs, if any. *
Do you currently have a sponsor? *
Do you have any Court, Probation or Children's Services cases that are currently open? *
Do you have any past or current mental health diagnosis? *
Are you currently on any medications? If yes, please list them. *
What do you hope to accomplish by coming to Her Story? *
Please share anything else you would like us to know.
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