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Streets of Joy Ambassador Application

Ambassador Information

First Name
Middle Name
Last Name
Date Of Birth
SSN
Phone
Previous Address
City
State
Zip Code
Age
Male Female
Height
Weight
Married:   Yes No
Have you used any substances in the last 72hrs 
Yes No
Drug of Choice:   Meth Alcohol Opiates Barbiturates
Other
Longest Period of Sobriety
Do you have any source of income:   SSI SSDI Death Benefits Food Stamps
Other
What’s your monthly income
What day does your benefits land on
Are you pregnant

Legal

Charges Pending:   Yes No
Nature of Charges
Do you have any warrants:   Yes No
If yes, where and when?
PO Name
County
Phone
Email
Public Defender/Attorney
Phone
Email
Do you need help with fees:   Yes No
If yes: Amount:
Past Criminal Charges:   Yes No
If yes, list dates
Are you a registered SO
UA Analysis

ALL APPLICANTS ARE SUBJECT TO BACKGROUND CHECK

Emergency Contacts

1st Contact
Relationship
Address
City
State
Zip Code
Phone
Email
2nd Contact
Relationship
Address
City
State
Zip Code
Phone
Email

Health Information

How would you rate your physical health:   Good Fair Poor
Do you have any medical problems:  
Yes No
If yes, explain
Do you have AHCCCS or Private Insurance
What AHCCCS plan are you on
Are you receiving Mental Health Treatment:   Yes No
Explain
Mental Health Provider/Clinic
Case Manager Info, Phone/Email
Have you been treated for mental illness in past:   Yes No
Diagnosis
Current Medications
How long have you been on them
Has the court ever ordered you to take medication:   Yes No
Do you take your medications as prescribed:  
Yes No
If No, explain
Have you ever over medicated yourself:   Yes No
If Yes, explain
Do you desire to get off of medications eventually:   Yes No
Do you have a seizure history

Interest In Recovery

Do you believe you have a serious problem with drugs:   Yes No
If Yes, explain
How do you believe Streets of Joy can help you
Describe four reasons why you want to enter this program
Have you ever had thoughts of suicide:   Yes No
Have you ever attempted suicide:  
Yes No
If yes, explain
Do you feel suicidal currently:   Yes No
YOU WILL BE WORKING AS A VOLUNTEER IN LIEU OF ANY CASH PAYMENT TO OFFSET LIVING EXPENSES:  
BY SIGNING BELOW, I ACKNOWLEDGE THAT I HAVE READ AND UNDERSTOOD THE RULES OF SOJ  
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