Application for Redeemed Recovery

Application for Redeemed Recovery

www.redeemedlife.us 423-455-5669
Criteria to be a resident:

- Must be a female.

- Must be at least 18 years of age.

- Must be 72-hours alcohol/drug free.

- Must be medically and mentally stable upon admission.

- Must be willing to participate daily in personal recovery.
Name

First NameLast Name
Gender
Date of Birth
Address Where You Currently Live

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Emergency Contact, Relationship & Phone Number
Probation Officer
Case Worker
AA/NA/Sponsor
Counselor/Therapist
Martial Status
Children & ages
Have you ever lived in a Recovery Residence before? If yes, please provide details
Prior treatment facility or centers and dates
Criminal Record w/ Dates and County
Are you a Sex Offender
Any Restraining Orders against you?
Do you have a history of violence or aggression towards others? If yes, Please explain
Date of last use of alcohol/drugs
Have you completed any addiction treatment programs or therapies? Please explain
Do you have any medical conditions or mental health diagnoses?
How long have you been using drugs/alcohol
List ALL drugs you have used in the past 2 years
Have you been prescribed any medications in the past 6 months? Please list
Current Employment status
Employer Name
If not employed, last time you were and where
Please share your reasons for applying to live in a sober living house
What specific goals do you hope to achieve during your stay in the sober living house
Are you committed to maintaining sobriety during your stay
Do you have a drivers license?
Do you have a sponsor or support system in place to help you maintain your sobriety? Please list:
Do you have any dietary restrictions or allergies
Do you have any physical or mobility limitations
Do you have a DL or State ID?
Do you have your birth certificate?
Do you have your Social Security card?
Do you receive food stamps?
Is there any other information you would like to share that you believe is important for us to know?
Agreement:

I hereby confirm that the information provided in this application is accurate and complete to the best of my knowledge. I understand that any false or misleading information could result in my application being denied or my expulsion from the recovery living house if I am already placed in a Redeemed Recovery House.
Signature
Should be Empty:

Application for Redeemed Recovery

Agreement: