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 *
Name *
First, Last
Your Age *
Date *
Your Phone number *
Spouse's Phone
Emergency Contact *
Emergency Contact phone *
How many
Clear selection
Names and ages
Are you pregnant *
If yes, what is the due date?
Nearest Relative *
Nearest Relative *
Have you ever been through an intensive in-house treatment? *
If yes where and when?
What drugs did you use? (list all) *
How long have you used drugs? *
Have you ever been molested? *
If yes, was it a family member?
Clear selection
Are you in trouble with the law? *
If yes, explain thoroughly
Probation Officer
List all court dates
Have you ever been charged as a sex offender? *
If yes, please explain thoroughly
Are you on any medications? *
If yes, list all and reason for use:
Do you have a job? *
If yes, where?
Do you have a valid drivers license? *
Do you have a motor vehicle *
How did you hear about this program? *
Are there any reasons you could not physically work in the home? *
If yes, explain how
Have you ever been diagnosed with anything? (sexually, mentally, physically, socially) *
If yes, explain thoroughly
Have you ever been violent? *
If yes, explain
Explain why you would like to be in this program *
Can you financially afford this treatment *
$3,000.00 Womens & Mens program
If yes, explain how
Previous Job Experience *
Parents and/or spouses employment *
Please leave as much info as possible
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.
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