APPLICATION for REDEEMED RECOVERY HOUSING

                              www.redeemedlife.us                                                              423-455-5669

Criteria to be a resident:

·Must be a female.

·Must be at least 18 years of age.

·Must be 72-hours alcohol/drug free.

·Must be medically and mentally stable upon admission.

·Must be willing to participate daily in personal recovery.

 

First Name:Text field           

Last Name: Text field

Gender M/F: Dropdown

Date of Birth: Text field

Address where you currently live: Text field

Please enter a valid phone number where you can be reached: Text field

Email:Text field

Emergency Contact, Relationship & Phone Number:Text field

Referral Source: Text field

Desired Move in Date: Date

Probation Officer & phone number:Text field

Case Worker:Text field

AA/NA/Sponsor:Text field

Counselor/Therapist:Text field

Martial Status:Text field

Children & ages:Family Members

SoberLivingHistory 

Have you ever lived in a Recovery Residence before? If yes, please provide details

Paragraph

 TreatmentCenterHistory

Prior treatment facility or centers and dates:

Paragraph

Criminal Record w/ Dates and County:

 Paragraph

Are you a Sex Offender? Dropdown

Any Restraining Orders against you?Dropdown

Do you have a history of violence or aggression towards others? If yes, Please explain

Paragraph

 Date of last use of alcohol/drugs:Text field

Have you completed any addiction treatment programs or therapies? Please explain

 Paragraph

 Do you have any medical conditions or mental health diagnoses? Please list

 Paragraph

 How long have you been using drugs/alcohol:Text field

List ALL drugs you have used in the past 2 years:

 Paragraph

Have you been prescribed any medications in the past 6 months? Please list:

 Paragraph

Current Employment status:Text field

Employer Name:Text field

If not employed, last time you were and where:Text field

Please share your reasons for applying to live in a recovery residence:

 Paragraph

What specific goals do you hope to achieve during your stay in the recovery residence?

 Paragraph

 

Are you committed to maintaining sobriety during your stay?Text field

Do you have a driver’s license? Dropdown          If not, state ID?Text field

Do you receive food benefits?Checkboxes

Do you have a birth certificate?Checkboxes

Do you have a social security card?Checkboxes

Health Insurance Provider: Text field

Do you have a sponsor or support system in place to help you maintain your sobriety? Please list:

Paragraph

 Do you have any dietary restrictions or allergies?Checkboxes

Do you have any physical or mobility limitations?Checkboxes

Is there any other information you would like to share that you believe is important for us to know?

Paragraph

Are you receiving welfare, unemployment compensation, disability payments, workman’s comp, alimony, VA benefits, or other income?

Checkboxes

Explain: Paragraph

How would you rate your personal health?

Checkboxes

Have you experienced or do you presently have a physical ailment, injury, handicap or medical problem that would prevent you from participating in Household Chores and obtaining employment while living at Redeemed Recovery Housing?

Checkboxes

IF YES, PLEASE EXPLAIN:

Paragraph

Agreement:

I hereby confirm that the information provided in this application is accurate and complete to the best of my knowledge. I understand that any false or misleading information could result in my application being denied or my expulsion from the recovery living house if I am already placed in a Redeemed Recovery House.

Sign Here:Signature

Date:Date