Promise of Hope, Inc. - Dudley, Georgia

Online Application for Admission

PRE-ADMISSION INFORMATION
First Name:
Last Name:
Address Line 1:
Address Line 2:
City:
State:		Zip:
		Primary Phone:
Age:		Birth Date:
Email Address:
Marital Status:		(M) (S) (W) (D) (Sep)
Gender:		Male Female
If divorced or seperated give date of seperation:
Spouse's Name:
Number of Dependent Children:
Church Affiliation:
Pastor's Name:		Church Phone:
Select Level of Education:
NAME & PHONE NUMBER OF EMERGENCY CONTACT
Contact Name:
Contact Relationship:
		Contact Phone:
PERSONAL MEDICAL STATUS
What type of drugs have you been abusing and how long (Be Complete about frequency and rate)?

Is there a history of substance abuse in your family? If so, please describe:

Is there a history of violence in your family? If so, please describe:

Have you ever had convulsions, seizures, or blackouts? If so, please describe:

Any known Allergies? If so, please describe:

Other Medical Problems? If so, please describe:

Are you taking any perscription medications? If so, please describe:

Rate yourself in the following: (Excellent, Good, Fair, Poor)
Physical Condition:		Excellent Good Fair Poor
Mental Condition:		Excellent Good Fair Poor
Emotional Condition:		Excellent Good Fair Poor
Spiritual Condition:		Excellent Good Fair Poor
LEGAL STATUS
Are you currently on parole, probation, under bond, or involved in any legal matters at this time? If so, please describe for what and how long:

Parole Officer Name:		Parole Officer Phone:
Who recommended Promise of Hope to you:

Have you attended a previous substance abuse program?

Comments or Other Important Information:

Letter of Motivation:
In filling out an application for entry into Promise of Hope, we ask that you write a letter of motivation, stating why you feel as though you want help at this time in the space provided below. Without letter of motivation your application will not be reviewed.

WELCOME TO PROMISE OF HOPE

Online Application for Admission