Application

Name

Phone

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Email Address

Date of Birth

Alternate Contact

Alternate Phone

Relationship Alternate Contact

Education LevelHigh School Grad/GEDSome College

Are you employedYesNo

Text

How many times have you been married?

Do you have any pending legal issues?YesNo

WarrantsYesNo

Please explain

Do you have a valid Driver's License?YesNo

Text

Do you have a Social Security card?YesNo

Have you ever been diagnosed and treated for any Psychiatric Disorders?YesNo

Cutting?YesNo

Eating Disorder?YesNo

Suicide attempt(s)?YesNo

Please explain

Do you have any physical or medical problems?YesNo

Please explain

Are you currently taking any prescription medications?YesNo

If yes, please lists the medications:

Do you smoke, vape or any other tobacco products?YesNo

If yes, which one(s) and how much?

Are you currently using any illicit drugs or alcohol?YesNo

If yes, what are you using, how much and when was the last time that you used?

Please list any previous drug/alcohol treatments:

Do you have any children?YesNo

If yes, how many?

What are the ages of your children?

Are you pregnant?YesNo

If yes, when are you due?

Briefly explain why you are applying to come into Rahab's Retreat and Ranch:

How did you learn about Rahab's Retreat and Ranch?

Are you willing to commit yourself to our program for a year?YesNo

Date

Month

Day

Year

Date signed