AWOL

PAY FEES

Admission Form

Admissions App

Personal Info

Some description about this section

First Name

Last Name

Mobile Number

Address

Address Line 1

Address Line 2

City

State

Zip Code

Date of Birth

Driver’s License & Insurance Info

Marital Status

Single

Married

Separated

Divorced

Desired Entry Date

Planned Exit Date

How did you hear about AWOL?

Emergency Contact

First Name

Last Name

Additional Details

Current/Past Drugs Used

Date of Last Use

Describe usage in the past 12 months

Current/Prior Treatment Facilities or Centers

Counselor/Case Manager

Phone

What were your aftercare plans?

Are you a registered sex offender?

Yes

If you are in the legal system, please explain.

If you have been convicted of a violent crime, provide details.

Parole/Probation Officer

Phone

Do you have ANY mental health issues or diagnosis?

Have you been prescribed any medications in the last 6 months?

Yes

List ALL medications you are currently taking and dosage and last date taken.

Doctor

Phone

Do you have ANY physical health/medical issues or disabilities?

Have you ever resided at a recovery/sober house before? (Y/N)

Why do you believe you would be a good fit at AWOL?

I certify that the answers provided above are true to the best of my knowledge.