Demi's Way Recovery Residence Resident Application
We are happy you are interested in Demi's Way Recovery Residence. To be considered for Demi's Way Recovery Residence, please fill out the application in its entirety and submit.
Personal Information
Name
*
First Name
Middle Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email
*
Confirmation Email
Social Security Number
*
Date of Birth
*
-
Month
-
Day
Year
Are you currently Homeless?
*
Yes
No
Gender at Birth
*
Male
Female
Current Gender
*
Male
Female
Emergency Contact
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number. This person will only be contacted in the event of an emergency.
What is you highest level of education?
*
Are you currently employed?
*
Yes
No
Employer Information
Company Name
Address / City / State
Position
Manager Name
Phone Number
If not employed, are you willing to become employed with 2 weeks of intake, complete applications daily and volunteer if not working?
*
Yes
No
Income: What is your monthly income?
*
Do you receive Social Security Disability etc? Include amount per month.
*
Do you have the $500 move in cost?
*
Yes
No
If approved, when would you like to move into Demi's Way?
*
-
Month
-
Day
Year
How will you pay your weekly program fee?
*
Do you have a vehicle?
*
Yes
No
Make and Model
License Plate
Is your vehicle registered?
Yes
No
Is your vehicle insured?
Yes
No
Are you willing to abide by all program rules and expectations and complete house chores?
*
Yes
No
Demi's Way require initial move in and random drug and alcohol testing. Are you willing to be tested randomly and upon request?
*
Yes
No
Do you understand that failure to follow program rules including refusing a drug test or a positive test are grounds for immediate discharge from the program at any time, day or night?
*
Yes
No
Demi's Way has zero tolerance for any drug or alcohol use, violence or threat of violence or bullying. These behaviors are grounds for immediate discharge. Do you understand these terms?
*
Yes
No
Are you a convicted sex offender?
*
Yes
No
Please provide information regarding any criminal history you may have. Are you on probation or parole? (include PO name/number).
*
Substance Use History:
What substances have you ever used? (Check all that apply).
*
Alcohol
Methamphetamine
Oxycodone
Fentanyl
Heroin
Morphin
Cocaine
Methadone
Opium
Amphetamine
Khat
Barbiturates
Benzodiazepines
GHB
Rohypnol
Ecstasy/MDMA
Ketamine
LSD
Peyote/Mescaline
Psilocybin
Steroids
Marijuana
Bath Salts/K2
DKM/Kratum
Other
When was the last date of use for any substance?
-
Month
-
Day
Year
Please note the last date of any drug or alchohol use.
Recovery: Do you have a sponsor?
*
Yes
No
Sponsor's Information
Name
Sponsor's Phone Number
Recovery: Please list the rehab program(s) and dates attended.
*
Have you previously lived in another recovery residence?
*
Yes
No
If yes, which recovery residence(s) and what dates did you live there?
*
How did you hear about Demi's Way?
*
What are your goals for your recovery?
*
What is your desired length of stay? (IE: 90 days, 6 months, 12 months)
*
Mental Health
Mental Health Needs: Do you have any mental health issues or diagnoses?
*
Please list ALL mental health diagnoses.
Medical Condition
Do you have any medical conditions that we should be aware of? Medical equipment, ongoing medical needs, etc.
*
Please list ALL physical health diagnosis.
Do you have any communicable diseases or other sexually transmitted health related conditions?
*
Please list ALL communicable health diagnoses.
Please list ALL medications you are prescribed for physical and/or communicable health conditions?
*
Please list ALL prescribed medications for physical and/or communicable health conditions.
Thank you for completing your application. Please press Submit below. A member of our staff will review your application and contact you shortly. Have a Great Day!!
Submit
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