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Waitlist Application
Have you previously participated in any programs with Restorative Partners?
*
Yes
No
Previous Programs
Mentor Program
Alternatives to Violence
Yoga
Art
Thinking for a Change
Other
Personal Information
Name
*
First
Middle
Last
Email
*
Phone
*
Date
*
MM slash DD slash YYYY
Address
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Legal Status
Are you able to pay for a part of your treatment/membership?
*
Yes
No
Are you currently incarcerated?
*
Yes
No
Incarceration Location
*
Incarceration Release Date
*
MM slash DD slash YYYY
Are you involved in any legal action?
*
Yes
No
Treatment History
Are you receiving alcoholism/drug addiction treatment?
*
Yes
No
Select all that apply to your treatment history.
Drug Court
Prop 36
AB109
POEG
ATCC
BATC
Self-Referral
Have you been treated at any of these locations?
SLO
North County
South County
Is your rent funded through your treatment program?
*
Yes
No
Contacts
Fill in all that apply
Phone
Treatment Counselor Name
Phone
Untitled
Phone
Drug History
Please describe your pattern of drug and alcohol use in the last 30 days:
*
How long since you've used drugs or alcohol?
*
What did you use last?
*
How long has using drugs and/or alcohol been a problem for you?
*
Employment
Employer Name
*
Phone
*
Untitled
Untitled
