Step 1 of 3 33% Date:(Required) DD slash MM slash YYYY Social Security:(Required)Date of Birth:(Required) DD slash MM slash YYYY Legal Name(Required)Middle InitialLastPhone Home:(Required)CellWorkCurrent Address:(Required) Address Apt City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific Zip Code Mailing Address Mailing Address Apt City State AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Zip Code Complete all sections of this application form. Incomplete or inaccurate applications may not be considered. If a particular section does not apply, write “does not apply”. Please complete the release of information found at the end of this packet if you have a referring probation officer, judge or treatment facility 1. Name, address, and phone number of treatment program you are currently involved with: Treatment Program:Phone:Address: Address Apt City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code 2. What is the date you entered the program: DD slash MM slash YYYY The date you are projected to be discharged: DD slash MM slash YYYY 3. Have you participated in previous treatment programs Yes No 4. Please list the treatment programs and the dates you participated in the program.: a)Dates DD slash MM slash YYYY b)Dates DD slash MM slash YYYY c)Dates DD slash MM slash YYYY d)Dates DD slash MM slash YYYY e)Dates DD slash MM slash YYYY f)Dates DD slash MM slash YYYY g)Dates DD slash MM slash YYYY Describe the reasons you did not complete any of the treatment programs:5. Please list all mood-altering chemicals you have used, how much, and the date of your last use: DRUG HOW MUCH DATE DrugHow MuchDate DD slash MM slash YYYY DrugaDates DD slash MM slash YYYY a)aDates DD slash MM slash YYYY a)aDates DD slash MM slash YYYY a)aDates DD slash MM slash YYYY Have you ever used mood-altering chemicals with a needle?(Required) Yes No 6. Are you under the care of a physician?(Required) Yes No 7. What is the name, address, and phone number of the physician: Physician:Phone:Address Address Apt City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code 8. Have you ever been evaluated by or are being cared for by a mental health professional?(Required) Yes No 9. What is the name, address, and phone number of your mental health professional: MH Provider:Phone:Address Address Apt City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code 10. If you are being treated for a mental health condition, what is the diagnosis?(Required)Are you prescribed or currently taking any medications:(Required) Yes No List of medications and dosages(Required)11. Have you ever had thoughts of suicide or attempts?(Required) Yes No Please list the last time you thought of suicide, had suicidal thoughts, or a suicide attempt.(Required)12. Please explain your history of legal involvement?13. Are you currently on Probation?(Required) Yes No Probation OfficerPhoneAddress(Required) Address Apt City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code 14. Why did you decide to seek treatment with this facility?15. How can this program and facility assist you in achieving your goals for recovery?16. What are your thoughts concerning self-help, support groups (ex.AA, NA)?17.Whom are you currently residing with?(Required)18. Do you have family in the Helena area?(Required) Yes No 19. Have you completed a physical screen/exam in the last 30 days?(Required) Yes No 20. Are you required to register as a: Sex Offender(Required) Yes No Violent Offender(Required) Yes No 21. Please answer the following questions. a) Have you ever used drugs with needles(Required) Yes No 1) If YES please indicate your last use(Required) Currently In the Last 6 Months In the Last 12 Months Other b) Are you currently homeless?(Required) Yes No c) Have you ever been diagnosed w/Tuberculosis?(Required) Yes No 1) If NO have you ever been screened?(Required) Yes No 2) If YES have you received treatment for?(Required) Yes No d) Are you currently receiving SSI or SDI? Yes No e) Do you have Private Insurance, Medicaid or Medicare?(Required) Yes No 1) If YES please attach a copy of your insurance information to application.Accepted file types: jpg, png, pdf, Max. file size: 50 MB. 22. Are you currently employed?(Required) Yes No Current EmployerPhoneAddress Address Apt City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code 23. What is your usual trade or occupation?24. After reading a copy of the standards and responsibilities, are there any standards that you disagree with?*Need a copy of Physical and TB test results within the last year. Signature of Applicant(Required)Date(Required) DD slash MM slash YYYY
