Application | The Purpose Sherpa

The Purpose Sherpa Program Application

To be considered for admission to The Purpose Sherpa's recovery program, please complete this application fully.

Personal Information

Your Name:

First Middle Last

Phone:

Best Time To Call You:

When is the best time for us to reach you via telephone?

Email:

Birthday

Race/Ethnicity:

Primary Language:

Gender:

How do you identify?:

Marital Status:

Are you a Veteran?:

Address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Emergency Contacts

Primary Emergency Contact:

Relationship:

Phone:

Family Member Contact Name:

Relationship:

Phone:

Insurance Information

Insurance Provider:

Insurance Plan:

Group ID:

Policy Number:

Other Insurance Details (if applicable):

Legal History

Do you consent to a background check?

Yes

No

Pending charges (if any):

Are you currently on probation?

Yes

No

If yes, date of last arrest:

Are you currently on parole?

Yes

No

If yes, release date:

Are you a registered sex offender?

Yes

No

Convicted charges:

Medication Information

List any medications you are currently prescribed:

Treatment and Housing History

Have you been admitted to treatment centers before?

Yes

No

If yes, provide details (facility names, dates, outcomes):

What facility (if any) are you transitioning from?

Who referred you to The Purpose Sherpa?

Have you been admitted to sober living facilities before?

Yes

No

If yes, provide details:

Program Details

Desired Admission Date:

Estimated Length of Stay:

Current Employment Status (Employed, Unemployed, Student

Why do you want to join a recovery home?

What is your recovery plan?

Signature and Acknowledgment

Date(Required)

Signature(Required)

I certify that all the information provided in this application is true and accurate to the best of my knowledge. I understand that false information may result in denial of admission.

The Purpose Sherpa Program Application

Purpose Sherpa Program Application

The Purpose Sherpa Program Application

Personal Information

Emergency Contacts

Insurance Information

Medical History

Legal History

Medication Information

Treatment and Housing History

Program Details

Signature and Acknowledgment