Application to J D Program Please submit your completed 2026

1. Click ‘Get Form’ to open the Application to J D Program in the editor.
2. Begin by entering the date at the top of the form. If you were referred by someone, indicate 'Yes' or 'No' and provide their name if applicable.
3. Fill in your personal information, including your name, date of birth, gender identification, marital status, phone number, social security number, mailing address, and email.
4. Indicate whether you are homeless and if you have a guardian or representative payee. Provide details about your preferred drugs and alcohol usage history.
5. Complete the legal information section by answering questions regarding any current legal charges or mandates for treatment.
6. In the health information section, provide details about your primary care provider and any major medical concerns. List any allergies or dietary restrictions as well.
7. Review all sections for accuracy before submitting. Once complete, save your document and follow instructions for submission via fax or call to confirm receipt.

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