Intake Form

All fields must be fully completed. Any false statements made on this application may result in denial of application and/or termination from our services.

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If yes Applicant may need to contact Dept of corrections EM department.

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Personal Information

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Legal Representation

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Please explain current housing situation

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Employment / Ability to pay

How will your account with Alaska Monitoring be paid?

If currently employed:

The following information is confidential and used to provide the court an appropriate release plan. All clients are subject to Random drug and or Alcohol testing

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Regarding the use of illeigal or Prescribed Drugs

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How long on a Scale of 1-10 where does the Applicant place for the use of.

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Click Submit to complete your purchase and turn in your application. Please review your information to make sure that it is correct.

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