Resident Application

The Lazarus Project of Knoxville

Program Application (All Programs)

Legal Name: Client first nameClient middle nameClient last name

Which program track are you applying for: Radio buttons

Current Address: Client AddressClient CityClient StateClient Zip

Telephone where you can be reached: Client phone Are you a felon? CheckboxesTOMIS# if Applicable: Text field

Are you required to report to the Sex Offender Registry?Dropdown

Have you ever been convicted or charged with any offense that is sexual in nature? Dropdown

DOB: Client birthdate SSN: SSN Marital Status:Client marital status

If you are LEGALLY married, please list the name of your legal spouse:Text field Race:Client race

Do you have a valid state ID or driver's license?Dropdown

Can you provide a copy of your birth certificate or social security card (even if it is a photograph)? Dropdown

Do you have a current capias/outstanding warrant in any county or state at this time? (Be honest, this does not disqualify you for admission, we could possibly help you with this.) Dropdown

If yes, please list the county, state and the charge: Text field

Were you recently released from jail on bond? Dropdown If so, please provide the bonding company:Text field

Occupation: Text field

Education (last completed):

Radio buttons

Currently in treatment or jail:

Radio buttons

If yes, where: Text field Anticipated release date: Date

Please describe the circumstances around the criminal charge (if any) that originally resulted in your current situation or incarceration (what happened... tell us your story... why are you in jail or how did you become addicted?):

Paragraph

Do you currently receive disability benefits:

Radio buttons

If so, what is the monthly amount? $Text field

Are you documented with law enforcment as a violent offender:

Radio buttons

Do you have any gang affiliations:

Radio buttons

Have you ever been in the military:

Radio buttons

If so, what branch: Text field How Long: Text field

Were you ever dishonorbly discharged from military service:

Radio buttons

If so, for what reason: Text field

Do you struggle with substance abuse/drug addiction:

Radio buttons

If so, please answer the blue questions below:

Drug of choice:

Client substances of choice

How often: Text field

How much: Text field

How do you use it: Text field

When did you start using drugs: Text field

Last time you used drugs: Text field

Criminal History:

Year	Charge	Sentence	County/State Convicted
Text field	Text field	Text field	Text field
Text field	Text field	Text field	Text field
Text field	Text field	Text field	Text field
Text field	Text field	Text field	Text field
Text field	Text field	Text field	Text field
Text field	Text field	Text field	Text field
Text field	Text field	Text field	Text field

Pending Criminal Charges:

Radio buttons

If yes, what are they? Text field

In what county: Text field Court Dates: Text field

Other upcoming court dates: Text field County: Text field

Regarding what charge: Text field

On Probation or parole:

Radio buttons

If yes, assigned officer: Text field County/State: Text field

Do you have an attorney/public defender:

Radio buttons

If yes, attorney's name: Text field County: Text field

How many children do you have: Text field Please list their names if they are under the age of 18: Text field

Current Medical Diagnosis or Problems: Client health problems Client categories Other medical information: Text field

Do you have any urgent medical or mental health concerns that would need to be addressed within 24 hours of your admission? Dropdown If so, please describe the concern:Text field

Medications: If none, write NONE (please include any medications you are supposed to be taking but do not have access to): Medication

Have you been in any type of substance abuse treatment before:

Radio buttons

If so, please list the names of facilities and the year you received treatment below: (this does not disqualify you, be honest)

Text field

Have you been incarcerated (more than 6 months at a time) before:

Radio buttons

If so, please list the dates and names of facility along with the associated charge below:

Name of Facility: Text field Dates: Text field Charge: Text field

What do you see as your main obstacle in life? (Why are you wanting our services?)

Paragraph

Describe yourself, what kind of person are you?

Paragraph

Emergency Contact #1:

Contact

Emergency Telephone Number:

Text field

Emergency Contact Address:

Text field

Emergency Contact Relationship to You:

Text field

Emergency Contact #2:

Contact

Emergency Telephone Number:

Text field

Emergency Contact Address:

Text field

Emergency Contact Relationship to You:

Text field

How long do you plan to stay at our facility? Text field

Do you understand and agree to participate in all activities and courses that are faith-based while a resident in our facility?

Radio buttons

What is your spiritual/religious preference?Dropdown

Do you agree to pay a weekly program fee of $200.50, a $500 deposit, and any other fees associated with services outlined in the Housing Guidelines (Arrangements can be made regarding the deposit, but must be made prior to admission)? Checkboxes

I understand I will be required to fully engage a minimum of 40 hours per week in a life skills/employment position (assigned by the program Employment Specialist) for the duration of the year program or as deemed appropriate for my specific, recommended treatment plan?Dropdown

Signature:Signature