Restoration House Application
A Program of CrossBRIDGE, Inc.
INSTRUCTIONS: FILL-IN COMPLETELY. Indicate None or N/A in blanks that don’t apply to you. Incomplete forms will be rejected.
SECTION 1: SUITABILITY
Restoration House is a rigorous, highly accountable Residential Recovery Support Services Program. It is not for everyone. Restoration House is literally an honest-to-God Program for men and women so sick & tired of being sick & tired that they will do whatever it takes to find a better way to live. If your way worked, you wouldn’t need what we offer. All who humble themselves and work this Program our way discover their past redeemed, their present transformed, and their future restored. Our way involves honesty & accountability in all things and relational abstinence for the duration. To determine whether Restoration House is right for you, check ONLY the boxes of those policies you KNOW you can live with for at least nine months. Mismatches between people & programs never end well.
Initials Text fieldUnapologetically Christ-Centered Twelve Step Recovery.
Initials Text fieldDaily MAP Meetings. Just showing up is not enough. MAP means Mandatory Attendance & Participation.
Initials Text fieldDaily Reading & Writing Assignments. You must be able to read, write, and communicate clearly. Daily written A.A. or N.A. Step Work and sponsor-verified completion of Steps 1-9 required to graduate.
Initials Text fieldMinimum Nine-Month Commitment: There are no shortcuts; it could take longer.
Initials Text fieldRelational Boundaries: Except for official business, all communication or contact (including calling or texting) with members of the opposite sex (or same sex if so oriented) is prohibited. Possessing or accessing pornography is also prohibited. If you are unwilling to fully embrace these standards, stop here. This Program will not work for you.
Initials Text fieldEVERYONE ENTERS AT LEVEL I. Level I Boundaries Include:
Initials Text fieldDestination Restrictions: Mandatory Meetings, job search, approved service work & official business only.
Initials Text fieldContact Restrictions: Beyond relational boundaries, all LEVEL I contact & communication is strictly limited to official business, employers, sponsors, Program leaders & same-gender Participants only. Waiver requests for limited LEVEL 1 contact with parents and minor children are reviewed on an individual basis.
Initials Text fieldSelf-Reporting Honor Code: All Participants are required to self-report Program policy violations and to report all others who fail to self-report, including Staff. In contrast to the cowardly, self-serving practice of snitching to deflect scrutiny & save ourselves, the Restoration House Honor Code saves lives by saving us from ourselves. Honor coding by everyone makes the Program safe for everyone. It is not optional; if you are unwilling to Honor Code, stop here.
Initials Text fieldDocumented Full-Time Job Search. Until you have a full-time job, your full-time job is finding one. No working Sundays before 1:00 p.m. or Monday through Friday after 6 p.m. without an approved waiver.
Initials Text fieldProgram Fees: Due in advance. $150/week or $480/month. A temporary balance of past-due fees is permitted during Job Search only. All past-due fees are subject to the 80% Rule.
Initials Text field80% Rule: Participants with past-due Program Fees must pay 80% of all funds acquired from any source until fees are current. Official employer documentation required on all earnings. Fees must be current to level up.
Initials Text fieldGrievance Process: A non-retaliatory Grievance Process is available to all for any perceived mistreatment.
Before moving on to the next page of the application, please read the following statement carefully and sign below:
"I swear or affirm I have been honest in my responses to all information requested herein. I give my consent to CrossBRIDGE to confirm all information provided."
Full Legal Name: Client first nameClient last name
Signature: Signature
Today’s Date: Date
SECTION II: PERSONAL BACKGROUND
Name: Client first nameClient last name
Client nickname
Contact Number: Client phone
Email: Client email
Date of Birth: Client birthdate
Gender: Client gender
Are you pregnant?
Radio buttons
A. ALCOHOL/DRUG USE: Nicotine user?
Radio buttons
—started @ age: Text field
Started drinking @ age: Text field Started drug use @ age: Text field
Preferred drug of choice: Client substances of choice
History of alcohol/drug abuse:
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B. GANG AFFILIATION: Any gang-affiliations ever?
Radio buttons
List gang(s): Text field Initiation date: Date Ranks, roles & titles: Text field
C. HOUSING & JOBS:
Dates and details of living arrangements for the past four years:
LivingArrangementHistory
Dates and details of Work History for the past four years:
EmploymentHistory
Highest grade completed: Diplomas, certifications, licensure, or marketable trade skills:
EducationHistory
Have you ever lived in recovery housing?
SoberLivingHistory
D. FINANCES: EXCLUDING JOBS LISTED IN SECTION C, list ALL sources of financial support during the past four years:
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What Valid IDs do you currently have?
Checkboxes
Currently employed or promised a job?
Radio buttons
Employer: Text field
Current SSI recipient?
Radio buttons
$ Text field/mo.
Former SSI Recipient?
Radio buttons
$ Text field/mo.
$190 Deposit required of ALL Applicants except those pre-approved for RHP ($150 for First Week Program Fee & $40 for MTA I.D. & Monthly Bus Pass). If someone else is paying your deposit, list name, relationship, & phone number for verification.
YOU WILL NOT RECEIVE AN ACCEPTANCE LETTER UNTIL DEPOSIT RECEIVED OR VALID ARRANGEMENTS VERIFIED.
E. RELATIONAL
1. Are you legally married? Client marital status. If unmarried, are you currently in a relationship (fiancée, domestic partner, girlfriend/boyfriend, etc.)?
Radio buttons
3. Are you a party, Plaintiff or Defendant, to an active Order of Protection or Restraining Order?
Radio buttons
If yes, share details:
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4. Do you have minor children?
Radio buttons
If yes, list Name/DOB & Name/Relationship of Legal Custodian of each:
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5. Are you court-ordered to pay child support?
Radio buttons
If yes, monthly Amount & Any Arrearage: Text field
F. OTHER
1. For ALL prescription medications you take or should be taking, list name/dosage/frequency/last refill date. Example: “Montelukast/10 mg/day/05-13-18.”
Medication
2. Do you have a Mental Health diagnosis?
Radio buttons
If yes, list diagnosis & date of last visit with a Case Worker or Treatment Provider:
Client diagnosis
Date of last visit with a case worker/treatment provider:
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3. Daily written Step Work, meeting attendance, & Program compliance are non-negotiable requirements. Do you have any physical, mental, emotional, developmental, relational, or personal issues that could interfere with your full participation/compliance?
Radio buttons
Please specify if you indicated yes:
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4. Do you own a motorized vehicle?
Radio buttons
No vehicles in Level I. Level II+ with RH Staff approval, valid TN driver’s license, insurance, registration, and ongoing compliance with all Program guidelines & requirements.
5. Emergency Contact Name/Relationship/Mailing Address:
Contact
6. Your Current Mailing Address: Client AddressClient CityClient StateClient Zip
7. Each RH Guideline serves a clear purpose, so we expect full compliance and sanction non-compliance. If your way worked, you wouldn’t need our help becoming a healthy, responsible adult. We know we’re strict and not for everyone, so please tell us why you want to come to this Program and any questions or concerns you may have.
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SECTION III: CRIMINAL JUSTICE BACKGROUND
Have you ever been incarcerated?
Radio buttons
PENDING Any outstanding warrants or scheduled court appearances?
Radio buttons
If yes, specify:
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CURRENTLY INCARCERATED
Location: Text field TOMIS # Text field
If Davidson County:
Radio buttons
OCA#: Text field
1. Sentence Details. Original Charge(s): Convicted of/Plead to: Date: Sentence: Range: Jurisdiction & Judge:
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Are you currently serving time on a Probation/Parole Violation?
Radio buttons
As of today, what is your RED (Release Eligibility Date)? Text field
2. Any Disciplinary Actions?
Radio buttons
If yes, share Details:
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3. Any Certificates Earned?
Radio buttons
If yes, share details:
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C. PRIOR CONVICTIONS
1. Are you on Probation/Parole?
Radio buttons
Judge: Text field Unsupervised Supervised: Text field
Start Date: Date End Date: Date P.O. Name & Phone: Text field
2. List all VIOLENT, SEXUAL, or DOMESTIC OFFENSES:
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3. Registered Sex Offender?
Radio buttons
Registry Details:
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4. Total Number of all convictions involving Drugs or Alcohol, including Probation/Parole Violations
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➨ IV: ALL APPLICANTS “I completed this application (check one):
Radio buttons
Name & Relationship: Text field
“I swear or affirm that my responses are true, accurate, and complete in every respect. I understand that Program acceptance, if granted, is conditioned upon the veracity of my responses. If accepted, I will promptly notify Restoration House Staff of ANY changes to information provided. I understand that acceptance does not guarantee a specific entry date; my entry date will depend upon availability of bed space at that time.”
Applicant Signature: Signature Date Signed: Date