Birthday*

Marital Status*

Do you have children:*

Ethnicity*

Do you consider yourself religious?*

Do you attend church?*

Have you ever used IV drugs not prescribed?*

When was the last time?*

Have you ever been dismissed from a treatment program or a recovery home*

My Sister’s House is not a medical facility and does not staff medical professionals. Therefore, you must be detoxed (drug and alcohol free) for a minimum of 7 days prior to your arrival. Do you agree?*

Are you under bond? *

Are you a registered sex offender? *

Are you on probation? *

Do you have a Probation Officer? *

Currently paying child support or alimony? *

Do you have an attorney?*

Are you ordered to complete a treatment program by a member of the court, as a result of a judgment or probation officer?*