New Beginnings Client Application

This form must be completed prior to being interviewed for residency at New Beginnings Hickory. The information provided will be used during the interview to determine if residency with us is the best for you at this time.

* Indicates required question

Client Information

First Name

Middle Name

Last Name

Preferred Name

Date of Birth

Age

Phone Number (where you can be reached currently)

Email Address

Street Address (most recent)

City

State

Zipcode

Referral Information

Name of Person or facility who referred you

Medical & Physical Information

Do you have any medical conditions?

Yes

Are you physically able to work?

Yes

Do you have any physical limitations?

Yes

Do you have any allergies?

Yes

Do you have any dietary restrictions?

Yes

Do you have a history of seizures?

Yes

Are you prescribed any medication by a doctor?

Yes

List all medications currently taking

Substance Use Information

What is your substance of choice?

What is the date of your last use?

List of other substances used in the past?

Have you been through detox after latest use?

Yes

If yes, where did you detox?

Have you been to previous recovery centers?

Yes

If yes, please list what center and indicate if you completed the program

Criminal And Work History

Criminal and Legal Issues

Do you have pending legal charges, court dates, or issues?

Yes

Are you on probation or parole?

Yes

Do you have any sexual offenses?

Yes

Have you been convicted of assault, arson or an offense involving a child, juvenile, minor or senior?

Yes

If yes to any above, please briefly describe the charges

If on probation/parole please list your officer’s name and contact number

Are you able to work on a full time, first shift job?

Yes

Maybe

What do you do for work or any previous skills you may have?

Are you currently working? If so, where?

Confirmation

Please check yes or no by each statement and type your name for your signature at the end

I understand that New Beginnings Hickory will be conducting a background check and will be verifying the statements and representations on this form.

Select a choice

Yes

I swear, under penalty of disqualification of residency at New Beginnings Hickory, that the above is true and correct. I authorize New Beginnings Hickory, its agents and assigns, to conduct background checks and verify any statement that I make. I further agree to hold harmless and free from any liability New Beginnings Hickory and its agents and assigns, and any person or organization providing I understand that New Beginnings Hickory will be conducting a background check and will be verifying the statements and representations on this form.

Select a choice

Yes

Please type your name to represent your signature.

Today's Date

New Beginnings Client Application

* Indicates required question

Client Information

Phone Number (where you can be reached currently)

Street Address (most recent)

Referral Information

Name of Person or facility who referred you

Medical & Physical Information

Do you have any medical conditions?

Yes

Are you physically able to work?

Yes

Do you have any physical limitations?

Yes

Do you have any allergies?

Yes

Do you have any dietary restrictions?

Yes

Do you have a history of seizures?

Yes

Are you prescribed any medication by a doctor?

Yes

List all medications currently taking

Substance Use Information

What is your substance of choice?

What is the date of your last use?

List of other substances used in the past?

Have you been through detox after latest use?

Yes

If yes, where did you detox?

Have you been to previous recovery centers?

Yes

If yes, please list what center and indicate if you completed the program

Criminal And Work History

Criminal and Legal Issues

Do you have pending legal charges, court dates, or issues?

Yes

Are you on probation or parole?

Yes

Do you have any sexual offenses?

Yes

Have you been convicted of assault, arson or an offense involving a child, juvenile, minor or senior?

Yes

If yes to any above, please briefly describe the charges

If on probation/parole please list your officer’s name and contact number

Are you able to work on a full time, first shift job?

Yes

Maybe

What do you do for work or any previous skills you may have?

Are you currently working? If so, where?

Please check yes or no by each statement and type your name for your signature at the end

I understand that New Beginnings Hickory will be conducting a background check and will be verifying the statements and representations on this form.

Select a choice

Yes

Select a choice

Yes

Please type your name to represent your signature.