Keys to the Kingdom Recovery
Program Application
Personal Information
Name
*
First Name
Last Name
Have you ever been known by a different name?
*
Yes
No
What is the other name you've gone by?
*
Date of Birth
*
-
Month
-
Day
Year
Date
Contact Information
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Consent to contact
*
I consent to be contacted by undefined via SMS, email, or phone using the information I provided for the purposes of reviewing my application.
Signature
*
Demographics
Sex
*
Please Select
Male
Female
Decline to respond
Other
Other sex:
*
Gender Identity
*
Please Select
Male
Female
Transgender Male / Transman / FTM
Transgender Female / Transfemale / MTF
Gender queer
Decline to respond
Other
Please specify your gender identity:
*
Ethnicity
*
Please Select
Decline to respond
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White
Other
What is your ethnicity?
*
Are you currently enrolled in school?
*
Yes
No
Do you plan on continuing your education?
*
Yes
No
Will you be part-time or full-time?
*
Part-time student
Full-time student
Are you a veteran?
*
Yes
No
Which branch?
*
Air Force
Army
Coast Guard
Marine Corps
Navy
Space Force
Date that you entered service
*
-
Month
-
Day
Year
Date that you left the service?
*
-
Month
-
Day
Year
Program Participation Fees
The K2K program charges $1,000 per month for a double-occupancy room, or $1,500 per month for a single-occupancy room. There is also a one time, non-refundable administration fee of $250.
Statement of understanding regarding program participation fees
*
I understand the program participation fees, including the one time, non-refundable fee, and that I am responsible for making sure these fees are paid in a timely manner.
Signature
*
How will you pay for the program?
*
I will pay myself
Someone else will pay
What is their name?
*
First Name
Last Name
What is their email?
*
example@example.com
What is their phone number?
*
Please enter a valid phone number.
What is their relationship to you?
*
Program Details
Have you been a part of this program before?
*
Yes
No
When did you leave the program?
*
-
Month
-
Day
Year
Why did you leave the program?
*
Do you have any concerns with sharing a room?
*
Yes
No
Please describe your concerns:
*
Room availability is on a first-come, first-serve basis
Are you able to perform household chores?
*
Yes
No
Please provide more details:
*
Current Living Situation
What describes your current living situation?
*
I am living by myself
I am living with my family
I am living with a roommate(s)
I am living at a program / facility / institution
I have no permanent place to live and I am currently experiencing homelessness
Which program / facility / institution?
*
Have you ever been in another housing program within the last 90 days (prior to your current housing)?
*
Yes
No
Which housing program?
*
Why did you leave?
*
Family
Please enter an emergency contact:
*
First Name
Last Name
Please enter the emergency contact's phone number:
*
Please enter a valid phone number.
What is your marital status?
*
Single
Married
Engaged
Divorced
Separated
Domestic Partner
Other
Please explain:
*
Do you have children?
*
Yes
No
Please explain (names, ages, custody agreement, etc):
*
Substance Use History
Select all that apply:
*
Alcohol
Amphetamine
Barbituates
Bupenorphine
Cocaine
Ecstasy (MDMA)
Methadone
Methamphetamine
Morphine
Oxy
PCP
THC
Bath salts
K2
Kratom
TCA
Fentanyl
Inhalants
Psychedelics
Other
Please list any drugs not mentioned above:
*
For how many years have you been using alcohol and/or drugs?
*
Give a rough estimate (in general)
Do you use nicotine / tobacco?
*
Yes
No
In what form(s)?
*
Vape, cigarettes, cigars, zyn pouches, etc.
Medical
Do you have any allergies?
*
Yes
No
Please list all allergies below:
*
How would you describe your current physical health?
*
Good
Fair
Poor
Do you have any physical health / medical conditions or disabilities?
*
Yes
No
Please describe / explain below:
*
Do any of the following apply to you (select all that apply)?
*
Hepatitis A
Hepatitis B
Hepatitis C
Immune system disorder
Sexually transmitted disease / infection (STD/STI)
Tuberculosis (TB)
None of the above
Do you have a history of seizures?
*
Yes
No
Please explain:
*
Do you use any of the following medical equipment (select all that apply)?
*
Walker
Cane
Wheelchair
Glucose meter
C-Pap machine
Specialized pillow
Other
None of the above
Please specify:
*
Mental Health
Do you have any mental health issues or diagnoses?
*
Yes
No
Please explain:
*
Do you have a history of self-harm?
*
Yes
No
Please explain:
*
Have you ever experienced any suicidal ideation, suicide attempts, or received inpatient treatment for self-harming behaviors?
*
Yes
No
Please explain:
*
Do you get along well with others?
*
Yes
No
Please explain:
*
Do you identify patterns in other areas of your life that may have addictive qualities (select all that apply)?
*
Internet
Food
Relationships
Money
Shopping
Gaming
Sex
Gambling
Other
None of the above
Please explain:
*
Medications
Are you currently prescribed medications?
*
Yes
No
Please list all medications:
*
Are you currently using any over-the-counter medications / supplements?
*
Yes
No
Please list all over-the-counter medications / supplements:
*
Treatment History
Are you currently in a treatment program?
*
Yes
No
Program Name
*
Program Type
*
Inpatient
Outpatient
Sober Living
Other
What kind of program are you in?
*
Estimated Discharge Date
*
-
Month
-
Day
Year
Date
Recovery
The Keys to the Kingdom Recovery program requires that you be actively working a program of recovery and attending at least five (5) meetings per week and have a sponsor within the first four (4) weeks.
Which 12-step meetings do you attend?
*
Alcoholics Anonymous (AA)
Narcotics Anonymous (NA)
SMART Recovery
Celebrate Recovery
Other
None
Explain:
*
What is your sobriety date?
*
-
Month
-
Day
Year
Date
Do you have a sponsor?
*
Yes
No
Are you willing to find and work with a sponsor?
*
Yes
No
Courts & Criminal Justice
Background Check
*
I consent to a background check as part of the entry requirement into the Keys to the Kingdom Recovery program.
I DO NOT consent to a background check.
Signature
*
Are you currently involved in any legal proceedings or criminal justice issues?
*
Yes
No
Explain:
*
Do you have a requirement for Community Service?
*
Yes
No
Explain:
*
Do you have any court ordered treatment requirements?
*
Yes
No
Explain:
*
Do you have any pending sentencing or jail time upcoming?
*
Yes
No
Explain:
*
Have you been charged or convicted of Arson?
*
Yes
No
Have you been charged or convicted of a Felony?
*
Yes
No
Have you been charged or convicted of any violent crimes?
*
Yes
No
Have you ever been charged or convicted of abuse or neglect of any person, including but not limited to disabled person, senior, or child?
*
Yes
No
Have you ever been charged or convicted of cruelty to animals?
*
Yes
No
Are you affiliated with any gang?
*
Yes
No
Explain:
*
Restrictions
Select all legal requirements that apply:
*
House Arrest
Probation
Parole
Drug Court
Other
None of the above
Explain:
*
Are you a registered sex offender?
*
Yes
No
Are you required to register with any other authority for any other reason?
*
Yes
No
Explain:
*
Are there any restraining orders filed either against you or by you?
*
Yes
No
Explain:
*
Admissions
When would you like to move in?
*
-
Month
-
Day
Year
Date
Do you have a personal relationship with anyone who works for Keys to the Kingdom?
*
Yes
No
What is their name?
*
How long would you like to stay at Keys to the Kingdom?
*
Less than 90 days
Between 90 days and 6 months
Between 6 months and 1 year
At least 1 year
Are there any issues that could prevent you from completing your stay at Keys to the Kingdom?
*
Yes
No
Explain:
*
Personal Statement
This is your opportunity to let us know who you are and why you want to be part of the Keys to the Kingdom.
Why do you want to live in a sober house?
*
How did you hear about Keys to the Kingdom?
*
What are your goals and expectations?
*
What makes you a good fit for sober living?
*
Employment
Are you able to work?
*
Yes
No
Are you willing to work, volunteer, or go to school at least 20 hours per week?
*
Yes
No
Are you currently employed?
*
Yes
No
Where?
*
How many hours per week?
*
How much and how often do you get paid?
*
Personal Finance
Do you currently have an income?
*
Yes
No
Please describe the source of income, how much you receive, and how often:
*
Are you able to afford both the $250 non-refundable fee and the monthly program participation fee ($1,000 for double-occupancy or $1,500 for single occupancy; per month)?
*
Yes
No
Transportation
Do you have a valid driver's license?
*
Yes
No
Driver's License Number:
*
Driver's License State of issue:
*
Do you have a car?
*
Yes
No
What is the make, model and year of the car?
*
Are you willing to be of service and help other residents get to meetings / get groceries / etc?
*
Yes
No
Sensitive Information
Social Security Number
*
Additional Information
Please enter any other information about yourself or your situation that you feel we need to know:
*
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