Name *

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Date of Birth *

MM

DD

YYYY

Emergency Contact *

First Name

Last Name

Emergency Contact Phone *

(###)

###

####

Have you previously resided at RAIL Women's Recovery House? *

Yes

No

Alcohol and/or drug(s) of choice? *

Select all that apply.

Alcohol

Cannabis (Marijuana/Pot/Weed)

Central Nervous System Depressants (Benzos)

Cocaine (Coke/Crack)

Fentanyl

GHB

Hallucinogens

Heroin

Inhalants

Ketamine

Khat

Kratom

LSD (Acid)

MDMA (Ecstasy/Molly)

Methamphetamine (Crystal/Meth)

Over-the-Counter Medicines

PCP (Angel Dust)

Prescription Opioids (Oxy/Percs)

Prescription Stimulants (Speed)

Steroids (Anabolic)

Synthetic Cannabinoids (K2/Spice)

Synthetic Cathinones (Bath Salts/Flakka)

Tobacco/Nicotine and Vaping

Date of last use *

MM

DD

YYYY

Are you currently employed? *

Yes

No

Have you been convicted of a misdemeanor or felony? *

Yes

No

Name of Case Manager

First Name

Last Name

Will you be on probation or parole while in housing? *

Yes

No

I authorize RAIL Women's Recovery House to exchange information as needed with any and all government or private parties and/or their representatives as it relates to the application process and housing status while living at the RAIL Women's Recovery House. I understand and agree that all payments to RAIL Women's Recovery House are non-refundable. I have read both statements above, understand its contents, and voluntarily agree to its terms. *

Yes

No

Today's Date *

MM

DD

YYYY