Form

EAGLE CHRISTIAN MINISTRIES, INC

Resident Application
After completing this application, call to schedule an interview.

(405) 365-7716
I consent to be contacted by Eagle Christian Ministries, Inc via SMS, email, or phone using the information I provided for the purpose of reviewing my application.

YesNo
Name

First NameLast Name
Contact Phone Number
Please enter a valid phone number.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Today's Date

MonthDayYear
Date
Date Avaiable for Move-In

MonthDayYear
Date
Age
Gender
Ethnicity

Declined to respondAmerican Indian / Alaskan nativeAsianBlack or African AmericanHispanic or LatinoNative Hawaiian or other Pacific IslanderWhiteOther
Describe Your Current Living Situation

I am living by myselfI am living with familyI am living with a roommate(s)I am living at a program, facility, or institutionOther
List 2 Emergency Contacts
Marital Status

SingleMarriedDivorcedWidowed
Are you fleeing a domestic violence situation?

YesNo
Do you have children? If so, how many and who has legal guardianship?
Are you in the process of family reunification through DHS or a guardianship?

YesNo
Education/ Technical training

G.E.D/ High School DiplomaSome CollageCollageTechnical School / Trade License
Do you currently have income? If so, Income source.
Do you have your own vehicle?

YesNo
Note: If you plan to use your own vehicle during residency, you must provide a copy of your valid driver's license and current insurance verification and registration.
Do you have a Substance Use Disorder and/or a Mental Health Diagnosis?

Substance Use DisoderMental Health DiagnosisBothNeither
If so, have you ever received treatment in-patient or out-patient? Where and when?
How long since last use?
Do you have a primary care physician?

YesNo
List current medications:
Do you currently need any physical accommodations?

YesNo
Do you currently have health insurance? If so, who is your provider?
Do you have any food or medication allergies?

YesNo
Current Legal Situation

Drug CourtMental Health CourtCommunity SentencingProbation/ ParoleG.P.S.Currently IncarceratedPending ChargesNone
Military Background

YesNO
Do you have any charges of violence or sexual offenses?

YesNoPending
In your own words, Why are you seeking to live in a sober-living home?
What are the steps that you think you need to take to avoid return to use?
We hope and pray that you are successful in your decision to be in recovery! In the event that you are accepted as a resident at one of Eagle Christian Ministries, Inc's homes and make a decision to return to use, who will come pick you up? Name and phone number:
Should be Empty:

EAGLE CHRISTIAN MINISTRIES, INC

After completing this application, call to schedule an interview.