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Application For The Boaz House
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Email
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Your email
I am willing to make a commitment with God to complete the program.
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Yes
No
How did you hear about The Boaz House?
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Your answer
Have you been to The Boaz House before?
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Yes
No
YOU MUST BE DETOXED PRIOR TO COMING TO THE BOAZ HOUSE! WE ARE NOT A DETOX FACILITY.
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Understood
First Name
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Your answer
Last Name
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Your answer
Address
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Your answer
Age
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Your answer
Date of Birth
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MM
/
DD
/
YYYY
SSN (Last 4 Digits)
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Your answer
Email Address
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Your answer
Telephone Number
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Your answer
High School Graduate or GED?
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Your answer
Highest grade completed
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Your answer
Did you attend college or trade school?
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Yes
No
Areas of study
Your answer
What's your occupation?
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Your answer
Do you have a job that you can return to when you leave The Boaz House?
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Yes
No
Are you a U.S. Military Veteran?
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Yes
No
Dates of Enlistment
Your answer
What was your military specialty, job or occupation?
Your answer
Type of Discharge
Your answer
Who are you living with now? Relationship?
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Your answer
Can you return there when you leave The Boaz House?
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Yes
No
Maybe
Marital Status
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Single
Married with a license
Separated
Divorced
Widowed
Do you have children?
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Yes
No
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