RECOVERYCHICK APPLICATION FORM
Note: Please answer all questions. If something does not apply to you, kindly write N/A.
Name:Client first nameClient last name
Birthdate:Client birthdate
Email:Client email
Contact Number:Client phone
Driver's License #:Text field
How did you hear about us? Paragraph
Do you currently attend church? Text field
What is the name of your church? Text field
Denomination preference? Text field
Are you currently in Recovery? Text field
Sobriety Date:Text field
Which drugs/alcohol have you used in the past and with what frequency? Paragraph
Are you currently on Medical Assisted Treatment (such as suboxone or methadone)? Text field
Are you currently in treatment or incarcerated?Text field
If so, where? Text field
Counselor's Name: Text field
Counselor's Email: Text field
Counselor's Phone Number: Client phone
Have you ever lived in transitional living before? Text field
If so, when? Text field
Did you complete the program?Text field
What was your reason for leaving?Paragraph
Have you ever participated in Christ-centered Recovery? (Celebrate Recovery) Text field
Are you willing to participate in Christ-centered recovery? Text field
Do you have a relationship with Jesus Christ? Text field
Please explain the importance of prayer and bible study in your life: Paragraph
Please write your personal testimony/life story and include why you think that RecoveryChick can help you succeed in your recovery journey.(We want to know about you - please include at least 2-3 paragraphs.) Membership applicants will be voted in by existing members of the house. The information you write on this page will be read at a Recovery Chick Healthy House meeting.
Paragraph
Criminal Background
How many convictions? Text field
What were you convicted of? Text field
Are you currently on probation or parole? Text field
Are you required to register as a sex offender? Text field
Medical History
Do you have any medical conditions that will prevent you from working and/or doing household chores? Paragraph
Mental health/psych diagnosis? Paragraph
List any prescribed medication and what you take them for: Paragraph
Vehicle Information
Make: Text field
Model: Text field
Year: Text field
Insurance Carrier: Text field
Financial Responsibility
The cost of staying at RecoveryChick Sober Living House is $750 per month, due on the 1st of each month, or $185 per week, due every Friday. In addition, there is a one-time, non-refundable $200 administrative fee required at intake. All dues must be paid on time according to your agreed-upon payment schedule.
How will you pay for your stay while at RecoveryChick Sober Living House? (Check box)
Checkboxes
Nme: Text field
Phone Number: Client phone
RECOVERY SERVICES
I understand that any recovery services offered at RecoveryChick Sober Living Home are exclusively Christ-centered in nature and are not subject to licensure or regulation by the Texas Commission on Alcohol and Drug Abuse. This program offers only non-medical treatment and recovery methods such as prayer, Christian 12-step study, moral guidance, spiritual counseling and scriptural study.
Signature: Signature Date: Text field
RELEASE INFORMATION
I hereby authorize the release of information to RecoveryChick to receive the assistance I am requesting. I further certify that all the information on this application is true and correct. I understand that RecoveryChick may verify the information on this application and that deliberate misrepresentation of information may deny me acceptance to the program at RecoveryChick.
I give RecoveryChick permission to discuss my case with other agencies, businesses, churches, attorneys, individuals, and any others deemed necessary to verify application information and/or identify additional sources of assistance. I understand that all information will remain as private as possible within these entities.
I have read, understood, and agree to the policies above regarding the Release of Information.
Signature: Signature Date: Text field