In order for us to serve your needs best, please take your time & complete our Resident Application thoroughly & honestly.

Please take your time and allow about 30 mins to answer all questions completely. Incomplete applications may hinder or delay your interview.

APPLICANT'S PERSONAL INFORMATION

Race (Providing this information is optional and will not be used for discriminatory purposes): *
Have you ever been in a drug recovery program before? *
Are you a smoker? *
If yes, are you willing to stop smoking? *

SOCIAL STATUS

Marital Status *
Do you have any children? *

IN CASE OF EMERGENCY

PARENTS (IF LIVING)

EDUCATION

RELIGION

Are you currently a Church member? *

DRIVING RECORD

Is your driver's license valid? *
Have you had any traffic tickets within the last 3 years? *

MEDICAL HISTORY

Drugs

Select all the drugs/alcohol you have been on or had been using and how long you have been using them:

Cocaine/Crack *
Marijuana *
Heroin *
Alcohol *
Nicotine *
Prescription Drugs *
Methamphetamine *
Other *

Mental Health

Have you ever been diagnosed or treated for: *
Have you attempted Suicide within the last 3 years? *
Have you recently been to a home, state, or private hospital within the last 2 years? *

General/Other

Rate yourself on the following health conditions:

Have you ever had convulstions, seizures or blackouts? *
Is there any chance you could be pregnant? *
Have you ever been verbally, sexually, or physically abused? *
Have you ever verbally, sexually, or physically abused someone else? *

Medical Insurance

PLEASE NOTE: WE ARE NOT A MEDICAL FACILITY AND CANNOT GIVE MEDICAL CARE. WE NEED TO KNOW WHO WILL BE RESPONSIBLE FOR MEDICAL EXPENSES INCURRED WHILE YOU ARE HERE.

Do you have medical insurance? *

LEGAL INFORMATION

Which legal situation currently applies to you: *
Are you scheduled to be in court or attend any hearings within the next six months? *

ADDITIONAL INFORMATION

Were you ever in the Military? *

PERSONAL LETTER