Life Change Questionnaire

Gateway Forge Program Application

Basic Information

MM slash DD slash YYYY
MM slash DD slash YYYY
Backup Contact Name(Required)

Program Information

Do you struggle with addiction?(Required)
Do you want to change?(Required)

Past Program History

Have you tried to change in the past?(Required)
Have you attempted or completed any programs in the past?(Required)

Personal Information

Do you currently have or need to be evaluated for any work restrictions?(Required)
Do you have a current Driver’s License or State ID?(Required)
Are you currently working with or required to work with Friend of the Court (FOC)?(Required)
Have you ever had a Criminal Sexual Conduct (CSC) conviction?(Required)
Do you object to us notifying law enforcement that you are here?(Required)
Do you have an open CPS case?(Required)
Do you object to us notifying CPS that you are here?(Required)