Confidential Application

This is a confidential application. Fill in all the applicable information below and hit summit. If your application is approved, a copy of this will be signed in the presence of the director of Good Samaritan Rehabilitation, or an authorized delegate of the director and will be kept on file by Good Samaritan Rehabilitation.

Sex

Male
Female

This is a required question

Name

First, Last

This is a required question

Your Age

This is a required question

Date

This is a required question

Your Phone number

This is a required question

Spouse

This is a required question

Spouse's Phone

This is a required question

Emergency Contact

Name

This is a required question

Emergency Contact phone

Phone

This is a required question

Names and ages

This is a required question

Are you pregnant

Yes
No

This is a required question

If yes, what is the due date?

This is a required question

Nearest Relative

Name

This is a required question

Nearest Relative

Relationship

This is a required question

Have you ever been through an intensive in-house treatment?

Yes
No

This is a required question

If yes where and when?

This is a required question

What drugs did you use? (list all)

This is a required question

How long have you used drugs?

This is a required question

Have you ever been molested?

Yes
No

This is a required question

If yes, was it a family member?

Yes
No

This is a required question

Are you in trouble with the law?

Yes
No

This is a required question

If yes, explain thoroughly

This is a required question

Probation Officer

This is a required question

Judge

This is a required question

Prosecutor

This is a required question

List all court dates

This is a required question

Have you ever been charged as a sex offender?

Yes
No

This is a required question

If yes, please explain thoroughly

This is a required question

Are you on any medications?

Yes
No

This is a required question

If yes, list all and reason for use:

This is a required question

Do you have a job?

Yes
No

This is a required question

If yes, where?

This is a required question

Do you have a valid drivers license?

Yes
No

This is a required question

Do you have a motor vehicle

Yes
No

This is a required question

How did you hear about this program?

This is a required question

Are there any reasons you could not physically work in the home?

Yes
No

This is a required question

If yes, explaine how

This is a required question

Have you ever been diagnosed with anything? (sexually, mentally, physically, socially)

Yes
No

This is a required question

If yes, explain thoroughly

This is a required question

Have you ever been violent?

Yes
No

This is a required question

If yes, explain

This is a required question

Explain why you would like to be in this program

This is a required question

Can you financially afford this treatment

$2500.00 Womens & Mens program

Yes
No

This is a required question

If yes, explain how

This is a required question

Previous Job Experience

This is a required question

Parents and/or spouses employment

Please leave as much info as possible

This is a required question

This is a 120 day program for women and 60 day for men. All contracts will be terminated after 30 days unless otherwise approved by the Director. This is only an application. It will be reviewed by the Director or an authorized representative and you will be contacted by phone. Thank you.