DOC Inmate Application for Admission
Name: Client first nameClient last name Date: Date
Date of Birth: Client birthdate Age:Text field Marital Status: Client marital status
Biological Sex: Client gender Gender You Identify As: Client gender
Preferred Pronouns:Client pronoun
Email: Client email Phone Number: Client phone
Are you currently in a relationship? Checkboxes If yes, please give details: Paragraph
Ages of Children:Text field
Do you have regular contact with your children? Checkboxes If no, please explain: Paragraph
Ethnicity: Client ethnicity
DOC Number: Text field Name of Jail/Prison: Text field
Currently Housed In: (Pick One) Low Security Medium Security High Security Dropdown
Why are you incarcerated? Paragraph
How long have you been incarcerated?Paragraph
Disciplinary Action while incarcerated?Paragraph
When do you expect to be released? Text field
Case Manager:Text field
Case Manager Phone Number: Text field
Case Manager Email:Client email
Case Manager Fax Number: Text field
When you are released will you be on Parole? Text field
How long will you be on parole? Text field
Have you ever been convicted or accused of a sexual crime? Checkboxes a Violent Crime? Checkboxes or Arson? Checkboxes
Please list all felonies and misdemeanors, including approximate dates:Paragraph
What are your addictions / drug(s) of choice? Client substances of choice
When is the last time you used:Date
How long have you used? Text field
What drugs have you used in the last year? Paragraph
Have you ever been to treatment: Checkboxes Where: Text field When:Date
What is the longest clean time you’ve had in the last 5 years? (including time in jail or prison) Text field
What is the longest clean time you’ve had in the last 5 years on the streets? Text field
What are your mental health challenges, if any? Paragraph
Do you have any gang affiliations? Checkboxes Are you on any prescription medications? Checkboxes
What medications:Text field
Are you planning to change prescription medications upon release? Checkboxes
If so, what new medications will you be taking? Paragraph
Do you have any diseases? Checkboxes If yes what? Paragraph
Do you have any physical limitations?Paragraph
Are you able to use stairs daily (up to 2 flights) to get to your bedroom? Checkboxes
Are you able to climb a ladder to a top bunk? Checkboxes If no, why? Paragraph
If no, can you provide documentation from a doctor that a bottom bunk is a medical necessity? Checkboxes
Are you able to work? Checkboxes When is the last time you worked? Text field
What type of work do you do?Paragraph
Other sources of income: Text field How much? Text field
Are you able to pre-pay $850 for your first month PRIOR to receiving an acceptance letter? Checkboxes
If yes, please list contact name and number so we are able to verify funds:Paragraph
Once at Lighthouse, will you be able to pay Monthly Fees of $750? Checkboxes
Why do you want to come to Lighthouse? Paragraph
Please rate yourself in the area of cleanliness/organization (On a scale of 1 to 10) Dropdown
(1 being very messy and 10 being OCD neat and clean)
Are you a heavy, medium, or light sleeper?Text field
Do you snore? Checkboxes
Have you participated in the program at Lighthouse previously? Checkboxes If yes, when? Text field
What is your level of interest in the Lighthouse Program? Dropdown
(1 being only minimally interested as a backup plan and 10 being 100% certain you will come to Lighthouse immediately upon your release if accepted)
What other facilities are you considering besides Lighthouse? Text field
Are you able to make a definite commitment to complete Phases 0-4 of the Lighthouse Program? Checkboxes
(This takes a minimum of 4 months and will be a condition of your parole. It could take longer if you do not phase up as quickly as possible.)
How long do you see yourself staying in a program like Lighthouse? Client estimated length of stay
If you are not able to come to Lighthouse, what will your living situation consist of upon your release? Paragraph
Certifications - Please initial each statement below.
I understand that it is a requirement to have a clean drug test to move into the Lighthouse, and at all times
while Participating in the Lighthouse program.
Initials Text field I understand that collection of urine specimens will be supervised by Lighthouse staff to ensure the integrity of the
urine.
Initials Text field I have read and understand the basic expectations of the Lighthouse Program, including employment, weekly
meeting, chore, and curfew expectations, and agree to fulfill these expectations if accepted to the program.
Initials Text field I have read and understand Lighthouse’s Medication Policy and agree to abide by it if accepted to the program.
Initials Text field I understand that Lighthouse regularly tests for specialty drugs including but not limited to: SubOxone, methadone,
kratom, spice, fentanyl, acid, mushrooms, gabapentin, etc.
I certify that all of the information I have provided on this application is true and complete to the best of my knowledge. I understand that if at any time during my participation in the program at the Lighthouse that the information I have provided is found to be inaccurate or incomplete it will be grounds for immediate discharge from the Lighthouse.
Signature: Signature Date:Date
Printed Name: Signature
By continuing, you agree that your electronic signature is the legally binding equivalent to your handwritten signature. Whenever you execute an electronic signature, it has the same validity and meaning as your handwritten signature. You will not, at any time in the future, repudiate the meaning of your electronic signature or claim that your electronic signature is not legally binding.
References to Assist in Admission Decision – Please list references who know you and your addiction history. Lighthouse prefers to have at least 1 professional reference and at least 1 personal reference.
Applicant Name: Text fieldText field Date: Date
Applicant DOB: Date Applicant SS#: SSN
Parole – Specify County Text field
Abundance Foundation: Text field
Probation: Text field
Larimer County Pre-Trial: Text field
Larimer County Community Corrections: Text field
Homeward Alliance: Text field
Summitstone Health Partners: Text field
Public Defenders’ Office: Text field
Department of Human Services: Text field
Catholic Charities: Text field
Attorney: Text field
Rescue Mission: Text field
Hospital: Text field
Harvest Farm: Text field
Doctor: Text field
Recovery Coach: Text field
Counselor/ Therapist: Text field
Colorado Dept of Corrections: Text field
Parents: Text field
Siblings: Text field
Children: Text field
Other Contact(s): Text field
Other Contact(s): Text field
Authorization to Release Confidential Information: I, Text fieldText field, authorize the Lighthouse to retrieve from, release to, and exchange information with the above listed people / entities. I understand that the purpose of this release of information is to assist with my admission decision. I understand that this consent is voluntary and will remain in effect for two years from the date signed, unless I revoke this consent in writing prior to that time.
Signature: Signature Date: Date
By continuing, you agree that your electronic signature is the legally binding equivalent to your handwritten signature. Whenever you execute an electronic signature, it has the same validity and meaning as your handwritten signature. You will not, at any time in the future, repudiate the meaning of your electronic signature or claim that your electronic signature is not legally binding.
Complete this portion only to REVOKE the Authorization to Release Confidential Information Above:
I, Text fieldText field, hereby revoke my authorization for the Lighthouse to retrieve from, release to, and exchange information with the above listed people / entities as of .
Signature: Signature Date: Date