First name

    Last Name

    Check the box that applies I will have transportation‎I will NOT have transportation‎

    Check all that apply I will be financial responsible for my own program fees‎I will have support from family/other for my program fees‎I will be enrolled in a form of higher education‎

    Check the box that applies I am employedI am NOT employed

    Check all that ApplyI am a recovering alcoholic‎I am a recovering drug addictI am planning to attend an aftercare program‎I am planning to attend an IOP program‎I am planning to attend 90 days of meetings‎

    Are you discharging from a substance abuse program? If yes, list facility name, address, counselor and phone number

    Do you take prescription drugs? If yes, list prescribed drugs, reason, prescribing doctor frequency of doses

    Do you have any pending court cases (other than moving violations) If yes, Explain: (Bond, Probation, Pending Court Case)

    Have you ever been convicted of a Felony? If yes, explain.

    Have you ever lived in a sober living home?YesNo

    How did you hear about Simply Grace?Treatment Center‎Friend‎Website‎CounselorOther‎

    Printed applicant name

    Type first and last name

    By inserting your name, you understand this application is for internal use only. The questions are designed to assist in utilizing resources to assist you in your recovery through accountability and aiding you in any obstacles you may need to overcome. Simply Grace respects privacy and anonymity and does not share applicants information. Simply Grace reserves the right to accept or deny any application.
    Use mouse or track pad to digitally sign your name[signature* signature-956]