Lifeline-connect Resident Application for Admission
Personal Data & Information
Date
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Month
 -
Day
Year
Date
Please list your Full Name, Address, and all contact Phone Numbers:
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Email
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example@example.com
Please upload a RECENT photo of yourself (shoulders and above, with a shirt on)
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Date of Birth
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Month
 -
Day
Year
Date
What is your Birth Place, & Current Age.
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Status of Drivers License:
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Valid
Expired
Never Applied for a Drivers License
If you have a Drivers License; What is your Drivers License Number? What State is it for? (if you don't have a drivers license, please put "None")
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Are you a citizen of the United States:
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Yes
No
Date available for Program:
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Month
 -
Day
Year
Date
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Emergency Contact Information:
Please list your Emergency Contact Name, Address, Contact Phone Number(s), Relationship to You, and their Email:
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Marital History:
Marital Status:
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Single
Married
Common Law
Separated
Divorced
Widowed
What is Current Wife's Name, Age, Address, Contact Phone Number(s), and Email? (if you are not currently married, please put "None")
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List Your Children and Their Ages: (if you have no children, please put "None")
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Name of Girlfriend or Fiancé. If Fiancé, then what is your scheduled wedding date. (if no girlfriend or fiancé, please put "None")
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Family Background:
Father's Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Mother's Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
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Education
Do you have a High School Diploma or GED?
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Yes
No
Do you whish to continue your education?
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Yes
No
Briefly describe your education or vocational goals
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Please list any College, University, Trade or Technical School you have attended and the years attended
Have you ever been diagnosed with a learning disability?
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Yes
No
If yes, briefly describe
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Work History
1. Please list your current/last employer, what your job description was, and reason for leaving/termination.
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2. If applicable - please list your 2nd to last employer, what your job description was, and reason for leaving/termination.
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Health
List any communicable disease(s) with which you have been diagnosed (if none put "None")
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When was your last physical examination?
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Do you take medication or need medical attention regularly?
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Yes
No
Do you understand that you will be responsible for bringing a 60-day supply of any medication that has been prescribed by your doctor, and approved by Lifeline-connect Staff for use if accepted to Lifeline-connect?
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Yes
No
List all medications, dosages, and purpose for medications (if none put "None")
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List all medications you are allergic to (if none put "None")
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List any activity restrictions due to a medical condition (if none put "None")
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Briefly describe your medical condition
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Do you have any special diet requirements (if yes, please explain)
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Do you have any health needs, including Dental, that will need attention in the next 6 months? If so, please briefly explain.
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How have you used the following drugs?
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Rows
Never
Once
Several
Regularly
Opiates
Alcohol
Marijuana
Cocaine/Crack
Hallucinogenic (LSD/Acid)
Inhalants (Glue, Gas, etc)
Methadone
Heroin
THC (Gummies, Edibles, Pill Form)
Morphine
Crystal Methedrine
PCP - Formaldehyde/Dip
Ecstasy/MDMA/Mollie
K2/Spice/Synthetic Weed
Amphetamines/Stimulants
Adderall/ADHD Meds
Benzodiazepines (Downers)
Xanax/Valium
List any additional drugs you have used and the frequency
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What is the first drug you used? What was your age?
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What is the main drug you used? How long?
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Have you used drugs intravenously? If so, list the drugs.
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Do you use Tobacco/Vape? If so, what form? (If no, please put "None")
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Religious Background
Do you believe in God?
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Yes
No
Do you believe in the Bible as the Word of God?
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Yes
No
Do you pray?
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Yes
No
Briefly describe a spiritual experience that sticks out among others?
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What is your current spiritual condition?
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What church do you attend regularly? When is the last time you attended? What is the Pastor's name and phone number?
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Have you ever been involved with the Occult? If yes, describe your involvement.
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Substance Abuse Recovery Background
Have you ever received treatment in a residential recovery center? If yes, please list the following of each: Name/Location of Program, Length of the Program, How long were you in the Program, Did you complete/graduate the program?
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Do you understand the purpose of Lifeline-connect?
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Yes
No
To experience recovery as you pursue God's purpose for your life, please describe the recovery theme in your own words and express what doing that would look like to you.
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Do you understand that if accepted; you are committing to completing at least 12 months in residency at Lifeline-connect? If yes, briefly describe any responsibilities that would prevent you from completing 12 Months in the program.
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Legal Records
Do you have any pending cases? If Yes, please list the following: When, Reason, Name of Attorney, Attorney's Phone Number(s), Attorney's Address.
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Do you have any outstanding warrants? If Yes, Briefly Describe for What Reason.
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Are you currently on Parole or Probation? If yes, for how long? Name of Parole Officer and their Phone Number(s) and Address. (if no, please put "None")
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List all Arrest and Institutions such as Jails, Prisons, Juvenile Detention Center, Etc. to which you were committed or admitted yourself. Name of Location, Date Confined, Reasons for Confinement, Length of Confinement, and Date of Release.
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Referral
Who Referred you to Lifeline-connect? What is their Address & Phone Number(s)? What is their Relationship to You?
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Are you ready to start the 7 Day Interview Process?
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Yes
No
If you selected "No" for starting the 7 Day Interview Process, please explain why below. If you selected "Yes" please put NA in the box.
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Signature Required:
By providing your signature below you verify that all the information you have provided is true to the best of your knowledge.
Signature
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Authorization for Background Check:
I hereby authorize Lifeline-connect to investigate my background and qualifications for purposes of evaluating whether I am qualified for Residency at Lifeline-connect.
Signature
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Submit
Submit
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