ARK TRANSITION VILLAGE
PARTICIPANT APPLICATION
Last Update 11 days ago
PERSONAL INFORMATION
First Name: ______________________
Middle Name: ____________________
Last Name: ______________________
Admission Date: ____ / ____ / ______
Date of Birth: ____ / ____ / ______
Gender:
☐ M
☐ F
☐ Trans
☐ Non-Binary
Phone No.: ______________________
Email Address: __________________________________________
Home Address: ___________________________________________
City: ___________________________
State: __________
Zip: __________
Do you own a vehicle?
☐ Yes
☐ No
If yes:
Year: __________
Make: __________________
Model: __________________
Color: __________________
License Plate Info:
State: __________
Plate Number: __________________
Exp Date (mo./yr.): ____ / ______
Insurance Co.: ______________________________
Policy #: _________________________________
Exp Date: ____ / ____ / ______
NOTE: Please provide staff with D.L. registration and car insurance paperwork.
Copies will go in your file.
How did you hear about this program?
____________________________________________________________
____________________________________________________________
Do you identify as someone who struggles with drugs and/or alcohol?
☐ Yes
☐ No
Do you plan on working a program of recovery? (12 Step based)?
☐ Yes
☐ No
Are you attending or will you be attending an IOP/OP Program?
☐ Yes
☐ No
If so, Program Name: ______________________________________
(Please add to ROI in section below)
Medications:
____________________________________________________________
____________________________________________________________
____________________________________________________________
Medical History/Issues:
____________________________________________________________
____________________________________________________________
____________________________________________________________
Have you ever been diagnosed with a mental illness?
☐ Yes
☐ No
If so, state diagnosis:
____________________________________________________________
Do you have any present or past physical problems?
☐ Yes
☐ No
If so, state diagnosis:
____________________________________________________________
Do you have any known allergies?
☐ Yes
☐ No
If yes, please describe what the allergy is, what happens if you become afflicted,
and what remedy should be taken:
____________________________________________________________
____________________________________________________________
Are you currently under the care of a physician?
☐ Yes
☐ No
If so, reason:
____________________________________________________________
Physician's Name: ___________________________________________
Phone No.: _________________________________________________
Currently working?
☐ Yes
☐ No
If so, where?
____________________________________________________________
Address:
____________________________________________________________
Phone No.: _________________________________________________
EMERGENCY CONTACTS
Name: ___________________________
Relationship: ____________________
Phone No.: _______________________
Name: ___________________________
Relationship: ____________________
Phone No.: _______________________
FINANCIAL CONTACT
(The person helping you out financially – if you are self-supporting, please leave blank.)
Name: ___________________________
Relationship: ____________________
Phone No.: _______________________
SUBSTANCE ABUSE FACILITY / SOBER HOUSING HISTORY
Name: ______________________________________________
Date Discharged: ____ / ____ / ______
Length of Stay: __________________
Did you successfully complete the program?
☐ YES
☐ NO
If no, why not?
____________________________________________________________
Name: ______________________________________________
Date Discharged: ____ / ____ / ______
Length of Stay: __________________
Did you successfully complete the program?
☐ YES
☐ NO
If no, why not?
____________________________________________________________
Name: ______________________________________________
Date Discharged: ____ / ____ / ______
Length of Stay: __________________
Did you successfully complete the program?
☐ YES
☐ NO
If no, why not?
____________________________________________________________
Name: ______________________________________________
Date Discharged: ____ / ____ / ______
Length of Stay: __________________
Did you successfully complete the program?
☐ YES
☐ NO
If no, why not?
____________________________________________________________
Sobriety Date: ____ / ____ / ______
Drug of Choice:
____________________________________________________________
LIST RECENT DRUGS USED
DRUG: __________________________
DATE OF LAST USE: ____ / ____ / ______
DRUG: __________________________
DATE OF LAST USE: ____ / ____ / ______
DRUG: __________________________
DATE OF LAST USE: ____ / ____ / ______
DRUG: __________________________
DATE OF LAST USE: ____ / ____ / ______
CRIMINAL HISTORY
Have you ever been convicted of a felony or misdemeanor?
☐ Y
☐ N
If yes, please explain:
____________________________________________________________
____________________________________________________________
____________________________________________________________
SEX OFFENDER / PREDATOR STATUS
☐ Y
☐ N
If yes, please explain:
____________________________________________________________
____________________________________________________________
____________________________________________________________
Convicted of crimes of violence or sexual in nature against the elderly,
children, or the disabled?
☐ Y
☐ N
If yes, please explain:
____________________________________________________________
____________________________________________________________
____________________________________________________________
PARTICIPANT ACKNOWLEDGMENT
Participant Signature: ______________________________________
Date: ____ / ____ / ______
Participant Print Name: _____________________________________
Date: ____ / ____ / ______
STAFF USE
Staff Name: _________________________________________________
Staff Signature: ____________________________________________
By signing this document, I attest that all above information is true and
accurate to the best of my knowledge. I also agree with having my photograph
taken to be used for internal staff purposes only.