Recovery Court Program Application Form

Full Name

First NameLast Name

Date of Birth

Date

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email Address

example@example.com

Home Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Current Legal Status

Briefly describe your current legal charges or case status

Have you participated in any treatment or rehabilitation programs before?

If yes, please provide details of prior treatment or rehabilitation (program name, dates, outcome)

Please indicate the primary substance(s) of concern

In your own words, why do you want to participate in the Recovery Court Program?

Emergency Contact Name and Relationship

Emergency Contact Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Reference or Support Person (Name, Relationship, Contact Info)