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Starry Sky

APPLICATION 

Birthday
Month
Day
Year
Do you have a sponsor?
Do you attend meetings?

Please list all of the medications that you are currenly on and their dosage.

Are you currently employed?

Please include name of program and case manager if applicable

Substance of Choice

Choose all that apply

Have you ever been convicted of a felony?
Yes
No
Have you ever been found guilty of a sexual offense?
Yes
No
Are you currently on probation?
Yes
No
Preferred Location

Depending on bed availability

By signing this form, you agree that the above statements are true and acknowledge you are familiar with the house rules and fees.

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