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]