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
How do you hear about New Beginnings?
Medical & Physical Information
Do you have any medical or mental health conditions other than Substance Use?
Are you physically able to work?
Do you have any physical limitations?
Do you have any allergies?
Do you have any dietary restrictions?
Do you have a history of seizures?
Are you prescribed any medication by a doctor?
Substance Use Information
Have you been through detox after latest use?
Have you been to previous recovery centers?
Criminal And Work History
Criminal and Legal Issues
Do you have pending legal charges, court dates, or issues?
Are you on probation or parole?
Do you have any sexual offenses?
Have you been convicted of assault, arson or an offense involving a child, juvenile, minor or senior?
Are you able to work on a full time, first shift job?
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.
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.