THE DUGOUT Men’s Recovery House

Resident Demographic Sheet

General Information

Today's Date

Cell Phone

Home Phone

Date of Birth

Age

Legal Information

Have you ever been convicted of a Felony? If so please explain:

Have you ever been charged/treated for violent/destructive behavior including domestic abuse or Sex Offender:

List all previous arrest(s) and current disposition:

Are you currently involved with the court system, CRO/PO? If so list charge/disposition of case/CRO/PO/Lawyer:

Will you sign a release form allowing The Dugout Men’s Recovery House to run a background check:

Yes

No

Employment

Occupation:

Employer:

Is your occupation what you want to be doing? If not, what is your ideal occupation?

Education

Highest level of education:

Some High School

GED

High School

Some College

If 'Some High School', please tell us which grade?

Religion

Denomination:

Church Affiliation:

Describe your spirituality and share how important your faith is to you and your recovery:

Marital Status

Single

Engaged (not living together)

Engaged (living together)

Living Together

Married

Separated

Divorced

Widowed

Describe your current relationship to your girlfriend/fiancé/spouse:

Children

Please name your children, their age, biological gender and your relationship with them?

Family History

Mother's Name and relationship (share anything you think might be relevant to your recovery):

Father's Name and relationship (share anything you think might be relevant to your recovery):

What is your greatest difficulty with your parents?

Birth Order:

Single Child

Oldest

Youngest

Number 2 of 3 or more

Number 3 of 4 or more

Number 4 of 5 or more

Number 5 of 6 or more

Total number of siblings, including yourself:

Name your siblings and describe your relationship with them (and anything you think might be relevant to your recovery):

Emergency Contact

Name:

Address:

Phone Number:

Problem or Stress Information:

What are you experiencing at present, list stressors/triggers, etc:

Have you had previous counseling/psychotherapy? If so, do you feel it was helpful?

Have you been diagnosed with any mental health disorder? If so, name of disorder and agency making diagnosis:

What do you wish to change in your life?

How do you expect The Dugout Men’s Recovery House to assist you in your Change(s)?

General Health

How would you rate your physical health?

Excellent

Good

Fair

Poor

Are you under the care of a physician?

Yes

No

If yes, what is who is your physician?

Please explain the reason for physician's care?

List all Prescribed Medication:

What is your drug(s) of choice (DOC):

Have you had previous In/Out patient chemical dependency treatment(s):

Yes

No

If yes please share your experience and outcome:

Do you have any questions and/or concerns regarding The Dugout Men’s Recovery House should you be accepted as a resident?

Briefly share why you feel you should be accepted into The Dugout:

Acknowlegement:

Your digital signature acknowledges that all the information on this application is true,
any false information will eliminate the applicant from residential consideration.

Digital Signature

Signature Date: