New Life Recovery Program This field is hidden when viewing the formNext Steps: Sync an Email Add-OnTo get the most out of your form, we suggest that you sync this form with an email add-on. To learn more about your email add-on options, visit the following page (https://www.gravityforms.com/the-8-best-email-plugins-for-wordpress-in-2020/). Important: Delete this tip before you publish the form.Which program are you applying for? Men's Program Women's Program About YouYour Name First Last Your Address Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code PhoneEmail This field is hidden when viewing the formBest Time to Call YouSelect A Time12:00 am12:30 am1:00 am1:30 am2:00 am2:30 am3:00 am3:30 am4:00 am4:30 am5:00 am5:30 am6:00 am6:30 am7:00 am7:30 am8:00 am8:30 am9:00 am9:30 am10:00 am10:30 am11:00 am11:30 am12:00 pm12:30 pm1:00 pm1:30 pm2:00 pm2:30 pm3:00 pm3:30 pm4:00 pm4:30 pm5:00 pm5:30 pm6:00 pm6:30 pm7:00 pm7:30 pm8:00 pm8:30 pm9:00 pm9:30 pm10:00 pm10:30 pm11:00 pm11:30 pmSocial Security NumberAgeDate of BirthMonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920EthnicityCurrently Living with:RelationshipMarriage Status Single Married Divorced Widowed Spouse's Name First Last Spouse's OccupationGive a one-word description of your life right nowAre you currently homeless? Yes No How long have you been homeless?Do you feel safe at home? Yes No EducationEducationSome High SchoolGraduated High SchoolG.E.D.Completed Community CollegeCompleted CollegeHighest grade completed, and reason you didn't continue?What year did you complete it?What degree/courses did you complete?What college degree/courses did you complete?FamilyDo you have any children? Yes No Are they currently in your custody? Yes No Do you have an open DHS or CPS case? Yes No Are you currently pregnant? Yes No Due DateMonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Children InformationNameAgeAddress Add RemoveClick the + to add more childrenMedical InformationDoctor's name Prefix Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. First Last Doctor's Address Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Doctor's PhoneDate of last visit MM slash DD slash YYYY Have you ever used needles Yes No Have you ever been tested for HIV/AIDS Yes No ResultsPlease list any other S.T.D. TestsTreatment history:Have you taken medication within the last year? Yes No Are you currently taking medication? Yes No Please list any medications you are currently taking.Present physical complaints or problems/major medical history:Have you ever had problems with: (check all that apply) Allergies Constipation Upset Stomach Dizziness Asthma Excess Fatigue Bleeding Insomnia Mental Problems Chronic Cough Digestive Disorder . Depression Dermatitis DT’s Epilepsy Diabetes Bad Back Weight Loss Dental Problems VD or Herpes Hearing Loss Diarrhea . AIDS Hepatitis High Blood Pressure Liver Problems Heart Disease Open Sores Difficulty Breathing TB Vision Problems Special Diet Please explain each problem selectedCriminal HistoryCharges PendingCourtAre you currently on probation/parole? Yes No Probation/Parole Officer Name First Last Probation/Parole Officer PhoneAre you currently in violation of your probation/parole? Yes No HistoryDateCity, StateChargeTime Served (Y,M)Facility Served Add RemoveClick the + to add additional chargeAttorney Information First Last Address Firm Name Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Have you ever been arrested for:Assault Yes No Substance related? Yes No Robbery Yes No Substance related? Yes No Criminal Sexual Misconduct Yes No Substance related? Yes No Release of Information I agree to the Release of Information.By checking this box I hereby authorize the Little Rock Compassion Center to secure information from and/or release information to any person, corporation, society, organization, government agency, institution, or any other entity regarding my case history and/or my circumstances. I also hereby authorize any person, corporation, society, organization, government agency, institution, or any other entity to release to the Little Rock Compassion Center any information regarding my case history and/or my circumstances. My case information will remain available indefinitely to the Little Rock Compassion Center.Applicant Full NameDate MM slash DD slash YYYY Signature Δ
