RESIDENT APPLICATION RESIDENT NAME * First Name Last Name DATE OF BIRTH * MM DD YYYY Email * PHONE (###) ### #### ADDRESS Address 1 Address 2 City State/Province Zip/Postal Code Country GENDER * MALE FEMALE UNSPECIFIED PREGNANT YES NO UNKKNOWN MONTHLY FAMILY INCOME EMPLOYED YES NO RETIRED SSI/DISABILITY EMPLOYER (IF EMPLOYED) HIGHEST LEVEL OF EDUCATION HIGH SCHOOL DIPLOMA GED/EQUIVALENT SOME COLLEGE ASSOCIATES DEGREE or HIGHER PREFER NOT TO SAY INSURANCE MEDICAID MEDICARE OTHER ARE YOUR REQUIRED TO REGISTER AS A SEX OFFENDER? YES NO HAVE YOU EVER BEEN CONVICTED OF A VIOLENT CRIME? YES NO HAVE YOU EVER BEEN CONVICTED OF ARSON? YES NO DO YOU HAVE ANY PENDING LEGAL CHARGES? YES NO IF YES, PLEASE EXPLAIN ARE YOU CURRENTLY ON PROBATION OR PAROLE? PROBATION PAROLE DOES NOT APPLY IF YES, LIST WHERE, REASON, NAME AND PHONE NUMBER OF SUPERVISING AGENCY IN THE LAST 6 MONTHS, WHAT IS THE LONGEST PERIOD OF TIME THAT YOU HAVE GONE WITHOUT USING ILLICIT SUBSTANCES? ARE YOU ABLE TO WALK AND TAKE CARE OF YOUR PERSONAL HYGEINE WITHOUT ASSISTANCE? YES NO WHAT IS YOUR DRUG OF CHOICE? HEROIN/OPIATES METHAMPHETAMINE ALCOHOL BENZODIAZEPINES MARIJUANA OTHER ARE YOU GOING TO BE EXPERIENCING DETOX SYMPTOMS? YES NO UNKNOWN DATE OF LAST USE Thank you for your interest in Healing Properties of West Virginia. A member of our team will get back to you as soon as possible.