Website Application - Magnolia House NH

1
Full name* This field is required.Please enter your full name
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First Name
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2
Your Case Managers Email* This field is required.We need this for all communication
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3
Phone number and Extension* This field is required.If you're in a program, we need the number to be able to connect with you
4
Social security number* This field is required.Please add you social security number
5
Address* This field is required.Current address or mailing address
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6
What Treatment Program Are You In?* This field is required. Please tell us about the program you are in and when you will be completing that program
7
Date of birth & age* This field is required.Please tell us your date of birth and age
8
Your gender* This field is required.Please tell us your gender or how you identify
9
Are you a US citizen?* This field is required.Please answer yes or no
YESNO
10
Do you have a physical form of ID?* This field is required.Please answer yes or no
YESNO
11
Marital status* This field is required.Please tell us your marital status
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12
Number of children* This field is required.Please tell us how many children you have and if they live with you
13
Are you pregnant, if yes what is the anticipated due date?* This field is required.Please tell is the anticipated due date
Yes or No with date
14
Employment* This field is required.Please add details of current and previous employment
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15
Have you ever been arrested/convicted of a crime including sexual offences?* This field is required.Please explain in as much detail as possible
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16
Are you or have you ever been diagnosed with a mental illness?* This field is required.Please give as much detail as possible including diagnosis and how long ago?
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17
List of drugs used including alcohol with date of last use* This field is required.Please give as much detail as possible
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18
Current program* This field is required.Name of program you're in, case managers name and email. Along with approx. date of completion.
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19
Do you have the ability to pay a weekly program fee and damage fee upon entry?* This field is required.Please answer yes or no (MUST HAVE ABILITY TO PAY THROUGH SELF PAY UPON ENTRY)
YESNO
20
Pre Application terms:

The information I have provided on this pre-application to The Magnolia House NH is true, accurate, and honest.

If any information that I have provided on this pre-application is untrue then The Magnolia House NH may deny my eligibility to take the full application and deny entry into The Magnolia House NH.

I also absolve The Magnolia House NH from any liability of any actions that I may take based on this information that I have provided as truth.

Weekly Program fee's are $300.00 per week and due every Friday. There is a $300.00 (1) time in-take fee due upon arrival. Magnolia House NH is not NHCORR certified abd with that you will not be able to utilize CHP or Doorways funding; You will need to be self-funded or find outside resources prior to arrival.

Resonable Accomodation Policy:

Magnolia House NH will work with those who have disabilities and provide reasonable accomodations to help them live and participate in one of our recovery homes.
21
Application Agreement* This field is required.Please check the box to agree
22
Date* This field is required.Date of application
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23
Signature* This field is required.Please draw or type your signature to legally agree to the application
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