Touchstone Housing Application

BUTTERFLY MOMENTS WOMEN'S RECOVERY HOUSING APPLICATION

SUBMISSION OF APPLICATION DOES NOT GUARANTEE ACCEPTANCE
The program is Tennessee Department of Corrections Approved housing providing Addiction Recovery Program Supports. The program length is three to six months with the opportunity to stay longer if court ordered or needed for sustained recovery.

Financial Responsibility

1. There is no application fee. If accepted, your final approval will begin upon receipt of nonrefundable $200 program administration deposit and two weeks program fees ($480.00 due upon acceptance).

2. Fees are $140.00 per week or $560.00 monthly in advance nonrefundable.

3. Any fees paid in advance will not be refunded and will be forfeited if you move or violate rule resulting in discharge.

4. Scholarship opportunities may be available. Please inquire.
Who referred you?

First Name Last Name
Please let us know how you heard of us: *

TREATMENT FACILITY PRISON/JAIL MENTAL HEALTH FACILITY
Facility Name *
Release Date

Month Day Year
Date
Parole Mandated? *

Yes No

APPLICANT INFORMATION

TOMIS #_________________________
Full Name *

First Name Middle Name Last Name
Other Names Used
Date of Birth

Month Day Year
Date
Phone Number

Area Code Phone Number
Permanent Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
In your possession?

Drivers License #__________________ social security card #_______________ Birth Certificate
Do you smoke? *

Yes No
List of all substances of abuse/addiction and the last date used for each Substance abuse treatment? When and where? Did you complete the program? *
List of current medications Have you ever been hospitalized for mental health? *
Do you have any special needs or MEDICAL requirements the we need to be aware of?: *

EMERGENCY CONTACT/REFERENCES
Person 1 *

First Name Last Name Relationship
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number
Release information to this person? yes or no*
Person 2

First Name Last Name Relationship
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number
Release information to this person? yes or no

CRIMINAL HISTORY
Have you ever been charged (whether or not resulting in a convicted, or pleaded guilty or "no contest" to a felony? *

Yes No
Are you required to register as a Violent or Sex Offender in any jurisdiction? *

Yes No
List arrest records and dates List upcoming court dates *
Acknowledgement of responses

Read thoroughly before signing
I hereby certify that the answers I have given in the application are true to the best of my knowledge. By signing below, I agree to abide by all legal agencies and program rules with the full knowledge that willful failure to comply will result in my discharge with loss of all deposits and/or prepaid program fees. I understand I am not entering into a lease. I am entering into a program which requires participation, or I will be asked to leave the property. I agree that I will in no way hold the Owner/Director or occupants of Butterfly Moments Inc. in any way responsible for any injuries or even death that may occur during program participation. I also give my consent for staff (or designate) to contact my listed references, family members, sponsor(s) and/or Probation/Parole Officer concerning my progress or welfare. I agree to a background check if deemed necessary. It is understood that I will not be discriminated against based on race, color, sex, religion, or national origin.
Person completing application *

First Name Last Name
Relationship *
Phone Number

Area Code Phone Number
Sign Here

Clear
Today's Date *

Month Day Year
BUTTERFLY MOMENTS INC. WOMEN'S RECOVERY CENTER

phone: (931) 802-9133 email: office@butterflymomentsinc.org 865 Gracey Avenue, Clarksville, TN 37040
Please verify that you are human *
Should be Empty:

Now create your own Jotform - It's free! Create your own Jotform

BUTTERFLY MOMENTS WOMEN'S RECOVERY HOUSING APPLICATION

APPLICANT INFORMATION

EMERGENCY CONTACT/REFERENCES

CRIMINAL HISTORY

Acknowledgement of responses

BUTTERFLY MOMENTS INC. WOMEN'S RECOVERY CENTER