Kathy's House Residency Application
Christian Alcohol and Drug Rehab and Discipleship Homes
Today's Date
*
-
Month
-
Day
Year
Date
Your Name
*
First Name
Last Name
Your gender:
*
Male
Female
Pregnant female
Your age:
*
Years
Date of Birth:
*
-
Month
-
Day
Year
Date
Race/Ethnicity:
*
Marital Status:
*
Single
Married
Divorced / Separated
Phone Number
*
Please enter a valid phone number.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Referred By:
Full Name
Referral Person's Phone Number:
Please enter a valid phone number.
What is your drug of choice:
*
Alchohol is a drug
When did you last use:
*
-
Month
-
Day
Year
Date
Why do you want to come to Kathy's House:
*
Describe your reason and what you hope to achieve
Are you a registered sex offender:
*
Yes
No
Are you taking any medications at this time:
*
Yes
No
If yes, what medication(s) and for what:
Are you physically able to take care of yourself:
*
Yes
No
Are you mentally able to comprehend a program of recovery:
*
Yes
No
Have you been tested for HIV Virus, AIDS, or Hepititus:
Yes
No
If yes, when:
-
Month
-
Day
Year
Date
If yes, what were the results:
POS
NEG
Do you have any court dates pending:
*
Yes
No
If yes, when is your court date:
-
Month
-
Day
Year
Date
If yes, what is your court date for:
Court dates must be postponed or taken care of before admission
Are you on probation or parole:
*
Probation
Parole
Neither
If yes, what for, where, and your officers name:
Applicant must contact officer - reports must be handled for 8-weeks
Are you presently receiving EBT (Food Stamps) benefits, if yes bring your card:
*
Yes
No
Do you have a valid drivers license:
*
Yes
No
Do you have any job skills:
Brief overview
THIS IS A CHRISTIAN REHABILITATION HOME FOR ALCOHOLICS & DRUG ADDICTS, WE ARE NOT A MEDICAL FACILITY. NOR ARE WE AHOMELES SHELTER.
YOU ARE REQUIRED TO HANDLE ANY PERSONAL BUSINESS PRIOR TO ADMISSION. NO LEAVING CAMPUS DURING PROGRAM TO HANDLE PERSONAL BUSINESS.
ARE YOU WILLING TO COMMIT TO A 1YEAR IN-HOUSE PROGRAM, AT NO COST TO YOU OR YOUR FAMILY?
*
Yes
No
Signature
*
Continue
Continue
Should be Empty: