Demi's Way Resident Application

Demi's Way 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 NameMiddle NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email

Confirmation Email
Social Security Number
Date of Birth

MonthDayYear
Which Residence are you applying for?
Gender at Birth
Current Gender
Emergency Contact

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number. This person will only be contacted in the event of an emergency.Format: (000) 000-0000.
What is you highest level of education?
Are you a Bradford Health Referral?
Which Estate were you referred from?
How were you referred to Demi's Way?
Are you currently employed?
Employer Information

Company Name

Address / City / State

PositionManager 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?
Income: What is your monthly income?
Do you receive Social Security Disability etc? Include amount per month.
Do you have the $500 Intake fee?
If approved, when would you like to move into Demi's Way?

MonthDayYear
How will you pay your weekly program fee?
Do you have a vehicle?
Make and Model
License Plate
Is your vehicle registered?
Is your vehicle insured?
Are you willing to abide by all program rules and expectations and complete house chores?
Demi's Way require initial intake and random drug and alcohol testing. Are you willing to be tested randomly and upon request?
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?
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?
Are you a convicted sex offender?
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).

Other
When was the last date of use for any substance?

MonthDayYear
Please note the last date of any drug or alchohol use.
Recovery: Do you have a sponsor?
Sponsor's Information
Name
Sponsor's Phone Number
Have you previously lived in another recovery residence?
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.
Take Photo
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!!
Should be Empty:

Demi's Way Resident Application

Personal Information

Substance Use History:

Mental Health

Medical Condition

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!!