Troy Dream Center - Apply Now

YOUR NEW LIFE STARTS TODAY

First Name

Middle Name

Last Name

Address 1

Address 2

County

City

State

Zip/Postal Code

Gender

Date of Birth (mm/dd/yyyy)

Age

T-Shirt Size

Primary Phone Number

Secondary Phone Number

Email Address

Marital Status
Single
Married
Divorced
Widowed

Spouse Name

Do you have children?
Yes
No

Have you ever served on active duty in the U.S. military?
Yes
No

Do you have any pending charges? (please put charges in space below)
Yes
No

Charges (include States with Charges)

Do you have an Attorney or Public Defender?
Yes
No

Attorney or Public Defender contact information

Do you give the Troy Dream Center permission to contact your Attorney or Public Defender?
Yes
No

Are you on Probation or Parole? (If so please fill out box below)
Yes
No

Who is your Probation or Parole Officer ( give officer's contact information below)

Do you give the Troy Dream Center permission to contact your Probation or Parole Officer?
Yes
No

When did you last use? What did you last use? (give dates)

List below any Mental or Physical health diagnosis you've had and when. (if no put NA)

List medications you are currently on and why (if none put NA)

Referred By

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