Kathy's House Residency Application

Kathy's House Residency Application

Christian Alcohol and Drug Rehab and Discipleship Homes
Today's Date*

MonthDayYear
Date
Your Name*

First NameLast Name
Your gender:*

MaleFemalePregnant female
Your age:*
Years
Date of Birth:*

MonthDayYear
Date
Race/Ethnicity:*
Marital Status:*

SingleMarriedDivorced / Separated
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / 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:*

MonthDayYear
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:*

YesNo
Are you taking any medications at this time:*

YesNo
If yes, what medication(s) and for what:
Are you physically able to take care of yourself:*

YesNo
Are you mentally able to comprehend a program of recovery:*

YesNo
Have you been tested for HIV Virus, AIDS, or Hepititus:

YesNo
If yes, when:

MonthDayYear
Date
If yes, what were the results:

POSNEG
Do you have any court dates pending:*

YesNo
If yes, when is your court date:

MonthDayYear
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:*

ProbationParoleNeither
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:*

YesNo
Do you have a valid drivers license:*

YesNo
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?*

YesNo
Signature*
Should be Empty:

Kathy's House Residency Application

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.