Second Step Application
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Email *
Name of person referring you to Second Step *
Location Applying For *
Name *
Address *
Phone *
Date of Birth *
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DD
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Relationship Status *
Custody of Children? *
Do you have a criminal record? *
If yes, what were the charges?
Emergency Contact Name *
Emergency Contact Phone *
Emergency Contact Relationship *
Do you have a driver's license? *
If so, is it valid?
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State
Have you ever had a DUI? *
Do you require any physical accommodations? *
Primary Addiction (select one) *
Other Addictions (select all) *
Required
Recovery Program Name *
How long were you in the program? *
Graduation Date *
MM
/
DD
/
YYYY
Do you take any prescription medications? *
If so, list the name, dose, purpose and prescribing physician for each medication.
Do you have any minor children? *
If so, list their names and ages.
Are you employed? *
If so, where and for how long?
Are you in school? *
If so, list the name of your school, dates of attendance and program or degree pursuing.
Income Sources (select all that apply) *
Required
A copy of your responses will be emailed to the address you provided.
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