New Resident Application
Date of Application
Personal Information
First Name
Last Name
Date of Birth
Address Line 1 (May not be an institution address; must be a forwarding or "next of kin" address)
Address Line 2
City
County where you last resided
State
Please select...
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Puerto Rico
Virgin Island
Northern Mariana Islands
Guam
American Samoa
Palau
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
White
Native Hawaiian or Other Pacific Islander
Postal Code
Social Security Number
Email
Phone (If you do not have a phone, please provide phone number of "Next of Kin")
Marital Status
Single
Married
Divorced/Separated
Widowed
Valid Drivers License
Yes
No
Drivers License Number
Vehicle
Yes
No
Highest Level of Education
Some High School
High School Graduate
Some College
College Graduate
Graduate or Professional School
Race/Ethnicity
Please select...
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White
Military Service
Yes
No
Branch of the Military
Discharge Status
Substance Abuse Information
Date of Last Drink or Drug
Drug of Choice
Alcohol
Methamphetamine
Benzodiazapine
Opiates
Marijuana
Heroin
Cocaine
Ecstasy
Other Stimulants
K2
Spice
Other
All Other Drugs Used
Were you Referred to Progress House
Check if Yes
Yes
Referred by?
Why are you motivated to be a resident?
Legal History
Felony Convictions
Yes
No
State of Conviction
Currently on Parole or Probation
Yes
No
County of Parole or Probation
Probation Officer Name
History of DOC Incarceration
Yes
No
Pending Charges
Yes
No
DOC #
Description of Legal History (if None, state "None")
Medical History
Are you currently being treated for a medical condition?
Yes
No
Describe Medical History
List All Current Medications
Are you currently seeing a counselor or therapist?
Yes
No
Describe Psychiatric History
Employment Information
Currently Employed
Yes
No
Current Monthly Income
Hourly Rate
Place of Employment
Employment Start Date
Collecting Unemployment
Yes
No
Collecting Disability
Yes
No
Emergency Contact
Emergency Contact Name
Relationship
Emergency Contact Phone Number
Are you a Former Resident of Progress House?
Yes
No
AFTER YOU CLICK "SUBMIT", YOU WILL BE ASKED TO REVIEW YOUR SUBMISSION AND SIGN (E-SIGNATURE)
Contact Information