OASIS WOMEN'S RECOVERING COMMUNITY

                                                                      a place for hope and healing since 1991



Oasis Women’s Recovering Community

13832 Polk Street, Sylmar, CA  91342

818-362-0986  phone            818-833-0922 fax            owrc@yahoo.com



Help Us Help Ourselves





Shop

Amazon  

Support

Oasis

Comedy @Oasis

Oasis Women's Recovering Community Application

Please answer all questions completely.

First and Last Name
What is your age?
Phone Number
Email Address:
Where have you been living?
Do you have a Social Security Card? Yes
No
If YES, What is your Social Security #?
Do you have a Calif. Driver's License or ID? Yes
No
If YES, What is your Calif. Driver's License or ID#?
Are you on Parole or Probation? Yes
No
"W" or Booking Number
Parole or Probation Officer's Name
Parole or Probation Officer's Phone/Email
Parole/Probation Office Location
Parole/Probation Office Fax#
Incarceration Location
What date were you released?
Do you have open court cases? Yes
No
When is your next appearance date and where do you have to be?

DRUG/ALCOHOL HISTORY

Please complete the following questions honestly!

1st Drug of Choice
How LONG have you been using?
How much DAILY USE?
2nd Drug of Choice
How LONG have you been using?
How much DAILY USE?
What other drugs have you used? How long and how much?
When was the last time you had a drink or used a drug?
How much daily and for how long?
Are you sober now? Yes
No
If YES, How many days sober?

FINANCIAL INFORMATION.  

Residents at Oasis Women's Recovering Community are required to pay for their program.  To determine how this will occur we require the following information.  All information is held in strict confidence. 

Are you receiving financial aid? Check all that apply. SSI - Soc Security
Unemployment
Disability
Alimony
AFDC
GR - General Relief
Other
None
How Long?
From what office do you receive aid?

MEDICAL/MENTAL HEALTH INFORMATION

Do you have PHYSICAL problems? If so, what are they?
Have you been HOSPITALIZED? Yes
No
What date were you HOSPITALIZED?
Where & how long was your hospitalization?
Have you attempted SUICIDE? Yes
No
If YES, How many times?
Why did you attempt SUICIDE?
WHEN, WHERE, WHY, did you last see a doctor?
Are you taking any medication? Yes
No
If YES, List medications you are taking.

PERSONAL HISTORY

How have you been supporting yourself?
Are you in a relationship? Yes
No
How long have you been in relationship?
Do you have CHILDREN? Yes
No
If YES, What are their ages ?
Where are your children?
Do you have difficulty with ... Reading
Writing
Vision
Speech
Hearing
Have you ever been in a treatment program? Yes
No
If YES, How many times?
If YES, Where were you in treatment?
If YES, did you ... Complete
Leave Early
Discharged
Why did you leave early or discharged?
Do you have knowledge of 12 step programs? Yes
No

OASIS WOMEN'S RECOVERING COMMUNITY is a 6 month program.   Please consider carefully and answer the following question.

Can you make a 6 month commitment to your self, your recovery and your future? Yes
No

This online form was provided by Freedback.