Apply For Services - Rich Recovery Services

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Rich Recovery Services Inc.
Application

Bold indicates a required field.

Date		Please enter a valid Date
Phone Number		Please enter a valid Phone Number
Name		Please enter a Name
DOC Number
Gender	Male Female	Please enter Male or Female
SS#
Address
City
State
Zip
How did you hear about Rich Recovery Services?
Have you been convicted of a crime ever?
Nature of Drug Conviction or Arrest
Do you have pending charges?
If yes, Date of Conviction(s)
If yes, State of Conviction(s)
Charges
Are you currently on probation/parole?
Name & Contact Number of Probation/Parole Officer
Name of Probation/Parole Officer
Contact Number of Probation/Parole Officer
Employer
Assistance Resource
What is your highest level of education?
Have you ever been in treatment?
If yes, Where/When?
Previous Treatment Center #1: Name
Previous Treatment Center #1: Address
Previous Treatment Center #2: Name
Previous Treatment Center #2: Address
Have you ever been treated for mental illness?
If yes, what was your diagnosis?
Do you have children?
How Many?
List their ages
Who do they live with?
Have you been clean and sober for at least 72 hours (3 days)?	Yes No	Please enter Yes or No
What type of services are you seeking?
All information from this application will be held strictly confidential.