Advocate House

p. O. Box 9083 Please contact Bobby Borders

Huntington, WV 25704-0083 at 304-208-0215 when you
Fax Number: (740) 451-0509 have a completed application.
Website: advocatehouse.com
Email Address: AdvocateHouse@yahoo.com

ADMISSIONS APPLICATION FOR INMATES

ALL BLANKS MUST BE COMPLETED!

Name: Inmate ID#: Date:

Age: Date of Birth: Marital Status:
Race: Height: Weight:
SSN: Education Completed:
D o y o u h a v e a p h o t o ID? Yes o r N o W h a t t y p e o f p h o t o ID?

AN INMATE ID IS NOT AN ACCEPTABLE ID FOR JOB HUNTING. YOU WILL NEED YOUR BIRTH CERTIFICATE AND SOCIAL
SECUIRTY CARD BEFORE YOU ARE RELEASED. IF YOU DO NOT HAVE A SOCIAL SECURITY CARD YOU WILL NEED YOUR
BIRTH CERTIFICATE AND AN UNOPENED LETTER FROM A DOCTOR'S OFFICE TO GET ONE.

H a v e y o u b e e n in o u r h o u s e b e f o r e ? Yes o r N o When:
W h y have y o u chosen o u r house?

W h a t is t h e d a t e o f y o u r n e x t p a r o l e h e a r i n g ?

Case W o r k e r ' s N a m e : Phone Number:

Case W o r k e r ' s E m a i l A d d r e s s :

Attorney' Name: Phone Number:

Attorney's Email Address:

MEDICAL/PSYCHIATRIC HISTORY
Psychiatric H i s t o r y Yes o r N o
Where? When?
Reason f o r admission:
C u r r e n t m e d i c a l c o n d i t i o n s i n c l u d i n g HEP C, AIDS,
HIV p o s i t i v e , e t c . :
Current emotional status:
Current Medication For W h a t ? Current medication For W h a t ?

H a v e y o u e v e r a t t e m p t e d suicide? Yes o r N o

ALCOHOL/DRUG TREATMENT PROGRAMS/HOUSES

Where: When: Length:
Detoxification: When: Length:
Revised: January 11, 2019
 ALCOHOL/DRUG HISTORY
Have y o u ever been t o AA? Yes N o Have you ever been t o NA? Yes N o
A r e y o u an a l c o h o l i c ? Y e s N o D a t e y o u last d r a n k :
A r e y o u an a d d i c t ? Y e s N o D a t e y o u last u s e d :
Seizures? Yes N o If yes d a t e o f last s e i z u r e :
H i s t o r y o f DT's? Y e s N o Blackouts? Yes N o
Marijuana? Yes N o Hallucinations? Yes N o
Cocaine? Yes N o Valium? Yes N o
List a n y o t h e r d r u g s a n d d a t e last u s e d :

Longest p e r i o d o f p r e v i o u s s o b r i e t y ?

EMPLOYMENT
W o r k experience: H o w long:
W o r k experience: H o w long:

Are you receiving any other form of compensation? If yes, what type?

LEGAL HISTORY
List all charges p e n d i n g :
Probation? Yes N o If yes f o r w h a t ?
P. 0 . N a m e : P. 0 . N u m b e r :

Parole? Yes N o If yes f o r w h a t ?

If yes t i m e r e m a i n i n g ?

A r e y o u a convicted f e l o n ? Yes N o For w h a t ?

H a v e y o u b e e n c o n v i c t e d in t h e last 7 y e a r s o f a d r u g f e l o n y ? Y e s N o If yes w h e n ?
H a v e y o u e v e r b e e n classified a s e x u a l l y o r i e n t e d o f f e n d e r o r sexual p r e d a t o r ? Y e s N o
Have y o u ever been convicted of arson? Yes N o

INCARCERATION HISTORY
W h e r e a r e y o u i n c a r c e r a t e d ? Include t h e address.

What are y o u r offenses?

What is t h e l e n g t h o f y o u r s e n t e n c e ? H o w long have you served?
What m s h a v e yv o u bh pe ep n ep n r on l l e d in w h i l e i n c a r c e r a t e d ?
Dp r o ge r aa m
What programs have you completed while incarcerated?

W e r e y o u p r e v i o u s l y i n c a r c e r a t e d ? Yes o r N o Where?
When? H o w long?
W h a t w e r e y o u r offenses?

W h a t is y o u r f i n a n c i a l p l a n t o pay t h e h o u s e f e e s a n d p u r c h a s e essentials?

Revised: January 11, 2019