RESIDENT APPLICATION
Date
*
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Month
-
Day
Year
Date
Proposed Date of Arrival
-
Month
-
Day
Year
Date
Name
*
First Name
Last Name
Gender
*
Date of Birth
*
-
Month
-
Day
Year
Date
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.
Addiction History
Date of Sobriety
*
-
Month
-
Day
Year
Date
Drug(s) of Choice
*
Have you ever been in the Resurrection Power program
*
Yes
No
Brief History
*
Relapse Patterns
Self-Identified Recovery Issues
Current Treatment Status
*
In-Patient
Intensive Outpatient
Outpatient
Halfway House
Jail/Prison
Self-Referral
Other
Name & contact information of treatment center
Counselor's recommendation for aftercare?
Medical History
Allergies
*
Current Health Issues
*
Current Prescription & Over the Counter Medications (name, amount, frequency)
*
Do you have any physical or mental disabilities that prevent you from doing chores, attending meetings or following the expectations of Resurrection Power
*
Employment Status
Are you currently employed
*
Yes
No
Other
Are you receiving SSI or other benefits
*
Yes
No
Work History
Training/Education
Income Source
If you are not employable, please give an explanation here
Legal History
Criminal History (please be honest, as we do a background check)
*
I have no criminal history
I am currently on probation
I am currently on parole
I have been charged with a violent crime
I have committed or have been charged with arson
I have a sex crime conviction
I am or will be on ankle monitoring
I have been convicted of a felony or have been incarcerated
Other
If you have answered yes to any of the above, please state in detail the circumstances of each of the offense(s)
Do you have any pending legal issues, court dates, our outstanding warrants? If yes, please provide details
County / Municipality of Probation / Parole
Probation / Parole Officer Name
First Name
Last Name
Probation / Parole Officer Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Relationships
Marital Status
*
Single
Married
Divorced
Dating
Other
Are you currently involved in a romantic relationship or have you ended a relationship in the last year
*
List children's names and ages. Do you have custody or receive visitation?
Miscellaneous
Would you bring a vehicle if accepted into our program
*
Yes
No
If you have a vehicle, do you have the following
*
License
Registration
Proof of Insurance
Not Applicable
Check those that apply
*
I have a valid drivers license
I have state photo identification
I have my social security card
I am missing important documents
Anything else you would like Resurrection Power to know
Feel free to upload any information to Resurrection Power
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