Intake Form for Care Providers

RestorationCity Resident Application
Personal Information
Full Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Birth Date*

MonthDayYear
Gender*
Employer
E-mail
Occupation
Drivers License # and State Issued
Marital Status
Social Security Number*
Spouse's Name
Number of Children
Emergency Contact*
Emergency Contact Phone Number*
Primary Care Provider
Primary Care Provider Phone Number
Height
Weight
Ethnicity
How did you hear about RC

Legal History
Have you ever been arrested?

YesNo
If yes, please describe. List dates/offenses/parole/probation
Are you currently:

On ParoleOn Probation

RestorationCity Process
For over 40 years, RestorationCity has helped bring restoration to individuals and whole families by providing a Christ-centered residential treatment program for victims of substance abuse and family violence.

RC serves as a “school of life” equipping residents for successful Christian living through parenting skills, vocational training, access to college and community outreach.

It is through the power of Jesus Christ alone that people are set free and in over 40 years, not one addict has ever gone through drug withdrawals at RC! To God be the glory!

RestorationCity is unique in that it is one of the only programs where “whosoever will” may come---including whole families, single parents, as well as single men and women.

Signature and Submission
Please type your name below to indicate your willingness to follow all RestorationCity procedures concerning your applying. After RC screens your application you will be required to undergo a physical, get tested for Covid and also get vaccinated in order to be accepted into our program.
Applicant's Signature*
Date*

MonthDayYear
Enter the message as it's shown*
Date of discharge
Should be Empty: