Joe's House

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Application Form

Thank you for your interest in Joe’s House.

This form is very long so be prepared with as much information as possible. At the end you will be asked to sign the form, simply type in your name and today’s date.

Note: You agree that by signing this application You are making a minimum 24-week commitment to Bridges of Dodge County and understand that you must be faithful in all that is required of you in order to graduate from the program. And that you agree to abide by all the rules of Bridges of Dodge County.

Please enable JavaScript in your browser to complete this form.

Name *

Application Date *

Current Address *

City *

State *

Zip *

Phone *

Email *

Date of Birth *

Place of Birth *

Place of Birth (state) *

Height/Weight *

Race *

Hair Color *

Tattoos? *

Describe Tattoos

Drivers License # *

Expiration Date *

D/L State *

Physical Disabilities or Defects *

Disabilities or Defects Explanation

Rate Your Health *

Poor
Fair
Good

Are You Taking Prescription Medications *

Prescription Meds

Non Prescription Meds *

Have you been tested for AIDS? *

Are you HIV positive? *

Have you been tested for Hepatitis A,B, or C? *

Are you Hepatitis A, B or C positive *

Have you tested positive for Syphilis? *

Have you tested positive for Ghonorrhea? *

Have you tested positive for Chlamydia? *

Are you currently under the care of a physician? *

Are you currently under the care of a psychiatrist? *

Doctor's Name

Have you ever been diagnosed with a mental illness? *

Mental Illness description

Military Service? *

Military Branch

Length of Service

Last Grade in School *

Job Skills *

Are you currently working? *

Work Location

Have you ever been arrested? *

How many times arrested

Arrest dates and reasons

Pending court dates

been If State

Anticipated release from prison, jail or rehab

Have you ever spent time in prison? *

If prison, where and how long

Are you on probation or parole? *

Parole agent and county

Parole agent phone number

Do you have any warrants for your arrest? *

Have you ever assaulted anyone? *

If yes, were you under the influence of drugs or alcohol? *

Have you ever committed the act of murder? *

Have you ever raped anyone? *

Have you ever thought about suicide? *

Have you ever attempted suicide? *

Is anger a problem with you? *

Have you ever been divorced? *

Are you in debt? *

How much debt

Are you a drug addict? *

Drug of choice

Are you an alcoholic? *

Do you smoke? *

Do you consider yourself addicted or attracted to pornography? *

Do you attend church? *

Do you believe in God? *

What is your religion?

Have you gone to treatment or rehab? *

Treatment/rehab location

Treatment details *

Inpatient
Outpatient
N/A

Treatment dates

Did you complete the treatment program? *

Explain why you want to be admitted to Bridges of Dodge County *

Contact Information

Contact Name *

Contact Phone *

Contact Cell *

Father's Name

Father's Address

Father's Phone

Mother's Name

Mother's Address

Mother's Phone

Spouse's Name

Spouse's Address

Spouse's Phone

Children's Names

Who has custody of the children?

Sibling's Name 1

Sibling's Age 1

Sibling's Sex 1

Sibling's Name 2

Sibling's Age 2

Sibling's Sex 2

Sibling's Name 3

Sibling's Age 3

Sibling's Sex 3

Sibling's Name 4

Sibling's Age 4

Sibling's Sex 4

Do you understand and accept that this program is Christian based? *

Is all the information that you have true to the best of your knowledge? *

Signature

Signature of Applicant *

JOE’S HOUSE

(Men’s Sober Living Facility)
PO Box 244
Beaver Dam, WI 53916
920-344-9179

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