Name___________________________Age ______Date of Application_________
Expected Date of Arrival/Release__________________________
Date of Birth____Gender__Race____Marital Status___Social Security No.________
Address________________________________________________Phone_________
Emergency Contact____________________Relationship___________Phone_______
Referred by_________________Sobriety Date_______Drug of Choice____________
Have you lived in a Recovery Home or Half Way House before? If the answer is yes list where and when__________________________________________________________
__________________________________________________________ Dates of treatment and where_____________________________________________
List of Medications____________________________________________________
List Health Problems_______________________Mental Health Diagnosis____________
Disability____Are you currently receiving SSI____ or SSDI ___
History of Arrest Charges______________________________________________
_____________________________________________________________________
List any Pending Charges_______________________________________________
Do you have children?________Are you currently in a relationship?____
Probation/Parole Officer name & address______________________________________
Are you currently Employed?___Where____________________Phone Number_________
Do you own a Car?___Make _______Model_________Do you have Insurance?_________
Please circle all forms of IDthat you have in your possession: Drivers License #_____________ State ID card- Social Security Card- Birth Certificate.
I give my permission for WOW to communicate with the staff of former housing, treatment staff or family members regarding my information that the WOW staff considers necessary.
Resident Signature____________________Date_________
Staff Signature______________________Date_____ Approved____Disapproved____
WOW TRANSITION House Inc
Fax: 615-883-2560
