Life or Death Recovery Application

Application/Intake Form – Life or Death Recovery Services

We are currently accepting applications from men aged 18+. Anyone applying must read the Resident Handbook and submit this completed application prior to interviewing. Upon acceptance, $400.00 intake fee is required prior to move in.  

PERSONAL INFORMATION

Birthday:

 

Social Security Number:

Marital Status:

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Do you own a vehicle?

Will you have your vehicle on-site?

Do you have a valid driver's license?

Are you commited to be responsible for your own transportation? (LDRS does not offer transportation assistance)

 

RECOVERY INFORMATION

Are you an alcoholic? 

Are you a drug adict?

Drug(s) of Choice?

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Who referred you to Life or Death Recovery Services? 

Do you attend 12-step meetings?

Do you have a sponsor?

  • Sober Living History #1

    name:

    description:

    address:

    city:

    state:

    zip code:

    admitted:

    discharged:

    estimated length of stay:

    reason for discharge:
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EMPLOYMENT INFORMATION

Are you currently employed?

Are you willing/able to get a job within 7 days of moving in?

Are you willing/able to be self-supporting?

Will someone else be helping you pay rent or deposit?

If so, who?

LEGAL INFORMATION

Ever been incarcerated?

Currently on probation/parole? (If yes include name and contact details of your parole officer in the notes below.)

Are you a registered sex offender?

 

MEDICAL INFORMATION

Select All Medical/ Psychiatric Conditions:

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Select All Mental Health Diagnosis:

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List all Medications:

Are you receiving Suboxone, Subutex, Methadone, Vivitrol, etc?

EMERGENCY CONTACTS (LIST TWO)

Contact #1:

Contact #1 Phone Number:

Contact #2:

Contact #2 Phone Number:

I have read and agree to all house rules, and I swear every word of this application is true. (signature required)


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