---Some High SchoolHigh School Graduate/GEDSome CollegeAssociate's DegreeBachelor's DegreeMaster's DegreeDoctorate/PhD/JD
Do you use tobacco?
If so, how much?
---Occasional Use1/2 Pack per Day1 Pack per Day2 Packs per Day>2 Packs per Day
Emergency Contact Telephone
Do you currently receive any other funding?
If so, what benefits do you receive?
Have you ever received any funding from RAF?
If so, when?
What is your drug of choice?
What non-prescribed drugs have you used in the past year? (check all that apply)
If "Other", please list
How many times have you been in treatment?
List where and when
How many times have you completed treatment?
Have you ever AMA?
If so, list where and when
Are you currently in outpatient treatment now?
If so, where
Have you done IOP before?
If so, when and where
Did you complete IOP?
Are you interested in IOP?
Clean date of all drugs and alcohol since:
Have you been to a 12 step meeting? (check all that apply)
Have you ever lived in a recovery house?
If so, where?
Would you be interested in living in a recovery house?
If so, where would you prefer?
Do you have any medical conditions or special needs?
If so, what?
Do you have any mental health issues?
Have you had a psychological evaluation?
If so, what was the diagnosis?
Do you currently take any medication?
Do you have a prescription for:
Are you currently employed?
If so, please list your employer and position?
What is your weekly income?
If not employed, are you willing to fill out seven (7) job applications per week until you find employment as a condition of receiving benefits?
Do you have any charges pending?
If so, what are they?
Are you on Probation/Parole?
If so, when does your probation/parole end?
Explain why this opportunity would change your life
Apply today and our care representatives will reach out to get you the help you need.
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