CCMI Transitional House Application
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1235 Ash St. Macon, GA 31201 | ph: (478-742-8926) | Fax: (478) 742-8927

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Personal Information
Full Name *
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Date of Birth *
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Race *
Current Address *
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Phone Number *
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Email address
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Personal Contact 1 (who do we call to get in touch with you?) *
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Personal Contact 2
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Substance Abuse History
Why are you applying to this program? *
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What has been your longest period of clean time/sobriety since you began using/drinking? *
What is your drug of choice? (check all that apply) *
Required
Relationship History
Are you in a relationship? *
Do you have children? *
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Criminal History
Are you on probation or parole? *
What is your P.O.'s name & contact info?
Your answer
Are you on the sex-offender registry? *
Do you have any warrants? *
Medical & Psychiatric History
Please list any medical or psychiatric diagnoses
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Please list all medications you are currently taking
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Financial History
What is your monthly income?
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Do you owe any child support? *
Background checks (with attached copy of valid ID), and medical tests must be dropped off on site or faxed: 1235 Ash St. Macon GA 3120 | Fax: (478) 742-8927
Application Checklist
Additional Comments
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