First Name: Middle Name: Last Name:

Home Address:

City: State: Zip Code:

Phone Number: Date of Birth: Male Female

Are you a U.S. Resident? Yes No

Social Security Number: CDC#

Education (Highest Grade Completed) Literate: Yes No

Employer: Occupation:

Address: Phone Number:

City: State: Zip Code:

Income: Per: Year Month Two Weeks Week Hour

Maritial Status: Single Married Divorced Domestic Partnership

Spouse/Domestic Partner's Name: Occupation:

Address: Phone Number:

City: State: Zip Code:

Number of Children: Currently Pregnant? Yes No

Children's Names:

Guardianship/Custody of Children: (please explain)

CPS Involvement: Yes No

CPS Caseworker's Name Phone Number

Have you ever been in an Inpatient, Residential or Outpatient Alcohol/Drug Program? Yes No

Facility Name:

Date Entered: Date Left/Completed:

Reason for Leaving:

Facility Name:

Date Entered: Date Left/Completed:

Reason for Leaving:

Have you attended 12 Step meetings? Yes No

If yes, please explain your experience:

Do you think you are an Alcoholic Addict ? (check all that apply)

What can Skyway House offer you?

Start with most recent first:

Substance: How used:

Frequency: Quantity used at one time:

Age at first use: Date of last use:

Substance: How used:

Frequency: Quantity used at one time:

Age at first use: Date of last use:

Substance: How used:

Frequency: Quantity used at one time:

Age at first use: Date of last use:

During the last 3 years have you been or are you now convicted of a crime that is alcohol or drug related? Yes No

During the last 3 years have you been or are you now convicted of a crime that is NOT alcohol or drug related? Yes No

Do you currently have charges pending in a court of law? Yes No

If yes, please list what the charges are and whether they are misdemeanor or felony charges:

Criminal History: (Please List any and all felony convictions, date, and charges)

Attorney's Name: Phone Number:

Probation/Parole Officer’s Name: Phone Number:

Are you a participant of Drug Court? Yes No

Are you a participant of Prop36? Yes No

Counselor's Name: Phone Number:

Upcoming Court Appearances And Stage Of Legal Process:

If incarcerated, what is your expected release date?

Name: Phone Number:

Address:

City: State: Zip Code:

Relationship to you:

Do you know or have you ever had a mental health diagnosis? Yes No

If yes, please give diagnosis, details and/or treatment plan


Primary Physician: Phone

Please list any prescribed and/or over-the-counter medications taken presently:

Do you have any medical conditions that would affect your stay in Skyway House?

History of suicidal/homicidal behavior or suicidal ideation? Yes No

If yes, please explain:

Are you currently on Medi-cal? Yes No

Do you have health insurance? Yes No

TB Test completed on: Result:

Head Lice check completed on: Result:

Referring Agency:

Funding Source/Agency:

Funding Contact Name: Phone Number:

Address:

City: State: Zip Code:

How do you feel about your use of alcohol and drugs?

What was your last experience with alcohol and drugs like?

I understand that any omissions, deletions or false information provided in this application may be cause of dismissal from the Skyway House program and /or denial of this application.

I agree