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YOUR NEW LIFE STARTS TODAY
Looking for a fresh start? get started on a new path, discover your potential and see what god has in store for your life. it's never too late to fulfill your full potential.
First Name
Middle Name
Last Name
Address 1
Address 2
County
City
State
Zip/Postal Code
Gender
Male
Female
Ethnicity
African American/Black
American Indian/Alaskan Native
Asian
Caucasian
Hawaiian/Pacific Islander
Hispanic
Italian
Other
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
Living Situation
Homeless
Family
Shelter
Friends
Other
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
Drug of Choice
Alcohol
Barbiturates
Benzodiazepines
Cocaine/Crack
Glue/Paint
Heroin
Inhalants (Snuffing)
LSD
Marijuana
MDMA (Ecstasy)
Meth
Mushrooms
PCP
Prescription Drugs
Speed
Tobacco
Other:
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)
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