Personal Data
First Name	* required
Last Name	* required
Date Of Birth	* required
Age	* required
Social Security Number	* required
Marital Status	Single Married Divorced
Insurance Type ID #____________________________ CONTACT INFORMATION. _______________________________
Contact Information
Home Addres- Street
Apartment Number
City
State
Zip Code
Home Phone
Work Phone
Cell Phone
Treatment History
Have you ever been a resident of a Serenity Lodge program before? Yes No If yes, please give dates of residency
Referring Agency (INCLUDE ADDRESS AND PHONE MUNBER)
Name of counselor
Please list any previous treatments (INCLUDE DATES OF ADMISSION AND DISCHARGE)
I realize that Serenity Lodge to which I am applying for residency has been established in compliance with the conditions of 2036 of the Federal Anti-Drug Abuse Act of 1988, P.L. 100-690, as amended which provides that federal money loaned to start the lodge, requires the lodge residents to (A) prohibit all residents from using any alcohol or illegal drugs, (B) expel any resident who violates such prohibition, (C) equally share household expenses, including the monthly lease payment, among all residents, and (D) utilize democratic decision-making within the group including inclusion in and expulsion from the group. In accepting these terms, the applicant excludes himself or herself from the normal due processes afforded by local landlord-tenant laws. ** A non-refundable security deposit of $140 is required of every person coming in. IF YOU READ AND AGREE WITH THE ABOVE STATEMENT, TYPE YOUR FULL NAME BELOW  * required
Current Legal Issues
Please indicate any current charges, court cases, probation that you are facing presently, Please include name, office and telephone number of any probation officer following your case.
Personal Statement
Briefly explain what you expect to gain from becoming a member of serenity lodge. Other comments that you would like to make:
New Residents Clients admitted into the Serenity Lodge should, if possible bring their own: *Bed linen for a single bed (including mattress cover, please) *Bath towels and toiletries *Laundry soap *At least a 30 day supply of any prescription medication and/or renewable prescriptions. -Thank You-
I have read all the material on this application forn including the limitations set forth in P.L. 100-690. I have answered each question honestly and want to achive a comfortable recovery from alcoholism and drug addiction eith out relapse. If you agree with the above, please type your full name below.  * required
Employment History/ Financial Resources:
Are you able to hold onto 35 hours per week of employment? Yes No
Please list the types of jobs you have held the most.
Are you on SAGA (State Administered General Assistance)? Yes No If yes please list your case #, your case worker, city and telephone number.
Family History
Family Origin: Please list the members of the family in which you grew up, and indicate any who may have substance abuse problems.
Family of Procreation: Please list any children, spouse, ex-spouse or significant others in your life currently.
Do you have dependant children? Yes No If "yes" how many dependant children are in your custody?
Educational History
Please indicate number of years completed and if degree was attained. H.S. Diploma/GED: College/Vocational School/Military: Graduate School:
Legal History
Past Legal Issues: Please indicate any past charges, convictions, prison sentences, DWI, Probations, paroles:
Substance Abuse History Please check all problem substances indicating Drugs of Choice and how each substance is used. Please indicate how often and for how long each substance has been used at the peak of your addiction.
SUBSTANCE	DATE OF LAST USE-DOC / METHOD / HOW MUCH / HOW OFTEN / HOW LONG
ALCOHOL
MARIJUANA
COCAINE
HEROIN
PRESCRIPTION MEDICATIONS
OTHER
What is your longest period of abstinace?
When was your most recent drug screen?
Psychiatric treatment History
Applying clients with co-occurring illness and/or who take psychiatric medications are not disqualified. Have your ever been treated for a psychiatric condition? (e.g. Depression, anxiety, bipolar, psychotic behavior, schizophrenia)?
Do you currently take medication psychiatric condition? Yes No If "yes", please indicate what medication is being taken, the dosage and the prescribing doctor.
Have you ever seriously thought of planning or attempting suicide? Yes No
Physical Condition
Do you have any medical or physical complications? Yes No Please explain
Have you had a PPD (Tuberculosis) test done within the past three month? Yes No
Thank you for taking your time in completing this on-line application.   When you have now completed this application please press the submit button below.