Resident Application

The Lazarus Project of Knoxville 

Resident Application 

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 TOMIS # if Applicable: Text field

DOB: Text field  SSN: SSN

Occupation: Text field

Education (last completed): 

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Currently in treatment or jail: 

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

Do you currently receive disability benefits:

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

Are you documented with law enforcment as a violent offender:

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Do you have any gang affiliations:

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 Have you ever been in the military:

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

Were you ever dishonorbly discharged from military service:

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If so, for what reason: Text field

Do you struggle with stubstance abuse or drug addiction:

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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
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Pending Criminal Charges:

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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 matter: Text field

On Probation or parole:

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

Do you have an attorney: 

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

Are you legally married: 

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If so, please list the full name of your spouse: Text field

How many children do you have: Text field If yes, their names: Text field

Current Medical Diagnosis or Problems: 

Text field

Medications, If none, write NONE: 

Medication

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

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

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

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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

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

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?)

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Describe yourself, what kind of person are you?

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Emergency Contact:

Text field

Emergency Telephone Number: 

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Emergency Contact Address:

Text field

Emergency Contact Relationship to You: 

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

Please describe the circumstances around the criminal charge that originally resulted in your current incarceration (what happened... tell us your story as to why you were convicted): 

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

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