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