Resident Intake Form • Bishop Street Recovery Ranch

Full Name *

First

Last

Email *

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone/Cell *

yes, Do list

Last Four of Social Security Number

Date of Birth

Age

Place of Birth

Driver’s License Number

Driver’s License State

Who referred you to BSBR?

Emergency Contact

Emergency Contact Name

Relationship

Emergency Contact Address

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone

Work Phone

Contact Phone

Marital Status

Spouse’s Name

Spouse’s Phone

Spouse’s Address

Address Line 1

Address Line 2

City

State

Zip Code

Do you have children?

Yes
No

List Children Names & Ages

Active 'No Contact' Order?

Yes
No

If yes, list individuals and where order is filed

Court-mandated classes

Military History

Branch of Service

Date of Entry

Date of Discharge

Rank

Type of Discharge

Eligible for VA Medical Benefits?

Yes
No

Legal History

Currently under legal supervision?

Yes
No

Legally mandated to recovery program?

Yes
No

Mandated by

Court
Parole Board
Other

Reporting details (method, frequency, time left)

Probation Officer’s Name & Address

Probation Officer’s Phone

Attorney’s Name & Address

Pending Items

Ever convicted of a sexual offense?

Yes
No

Ever been in jail/prison?

Yes
No

Names and dates of incarceration

Arrests & Convictions (include drugs/alcohol involvement)

Financial Information

Receiving Assistance

How can you contribute to BSBR?

Do you have an income?

Yes
No

Amount in Savings

Amount in Checking

Court fees/fines, DOC fees, child support, alimony

Occupational History

Work Experience

Other work experience

Physical ailment preventing work?

Yes
No

If yes, please explain

Spiritual Background

Are you a member of a church or religion?

Yes
No

If yes, identify church/denomination/religion

Recovery

Reasons for seeking entry

Receiving treatment for psychological problems?

Yes
No

Physician’s Name

Physician’s Phone

Program Name

Program Location

Applicant’s Signature

Clear Signature

Date

Reason applicant could not complete form (if filled by another)

Signature of person completing

Clear Signature

Date (of person completing)