Application | Foundation Gate

Foundation Gate Application

Name*

Email*

Phone*

Married*

Yes

No

Date of Birth*

Referral Information*

Currently in Treatment?

Yes

No

Are you an addict?

Yes

No

Drugs of choice?*

List current prescription medications and purpose*

Date of last use

Are you employed? if yes, what company?

Are you receiving county or outside assistance? If yes, from where?

What is your total monthly income right now?*

Are you currently on probation or parole? If yes, include the name of your parole agent or probation officer including their phone number

Message*