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Program Application Form
Name
*
First Name
Last Name
Address current/last
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
*
(###)
###
####
Email
*
D.O.B
Family History & Structure
How long have you been in the foster care system?
Do you currently have contact with your biological family?
*
If so, who?
Do you have children?
*
Yes
No
Do you believe you might be pregnant?
Yes
No
Not Applicable
Please list 3 supportive adults in your life.
Please include contact info.
Education & Employment
Education Level
Some High School
High School Diploma or GED
Some College
College Graduate
Currently Employed?
Yes
No
If so where?
Legal History
Have you ever been in a juvenile detention center?
if so, please provide details.
Have you ever been arrested as an adult?
if so, please provide details.
Are you currently on probation or out on bond?
If so, please provide details.
Housing History
What was your last stable address?
Please include length of stay.
Where did you sleep last night?
Mental Health & Substance Abuse History
Have you ever been admitted into a mental health facility?
If so, when and where?
Have you ever been admitted to a substance abuse program?
If so, when and where?
Have you previously had or are currently in counseling?
If so, please provide where and when.
Have you tried or currently use any of these substances?
*
Check all that apply
Alcohol
Tobacco
Marijuana
Meth
Heroin
Cocaine
Other
If yes to any of those, please describe.
Have you ever attempted suicide?
If so, when was the last time?
Have you ever cut yourself?
If so, when was the last time?
About Yourself
Describe what you like about yourself.
Describe favorite hobbies, activities, and things you would like to try.
What areas would you like to improve in?
How can Act to ACT help you?
By typing your name in the field below and clicking submit, I attest to the truthfulness of all the information I have provided.
*
Thank you!
