Kathy's House Residency Application
Christian Alcohol and Drug Rehab and Discipleship Homes
Today's Date
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-
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.
Format: (000) 000-0000.
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.
Format: (000) 000-0000.
What is your drug of choice:
*
Alchohol is a drug
When did you last use:
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Month
-
Day
Year
Date
Why do you want to come to Kathy's House:
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Describe your reason and what you hope to achieve
Are you a registered sex offender:
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Yes
No
Are you taking any medications at this time:
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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:
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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:
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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
WE ARE A CHRISTIAN REHABILITATION HOME DEDICATED TO HELPING INDIVIDUALS OVERCOME ADDICTION TO ALCOHOL AND DRUGS. PLEASE NOTE, WE ARE NOT A MEDICAL FACILITY OR A HOMELESS SHELTER.
YOU ARE REQUIRED TO HANDLE ANY PERSONAL BUSINESS PRIOR TO ADMISSION. NO LEAVING CAMPUS DURING PROGRAM TO HANDLE PERSONAL BUSINESS.
ARE YOU READY TO COMMIT TO A 1-YEAR RESIDENTIAL PROGRAM—COMPLETELY FREE OF CHARGE TO YOU AND YOUR FAMILY?
*
Yes
No
Signature
*
Continue
Continue
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