Residential Application

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.

Social Number

Race/ Ethnicity

Highest Level of Education

Veteran Status

Religion/Faith

Parents and Spouse Details

Parent 1 Name (if applicable)

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Parent 1 Phone Number

Please enter a valid phone number.

Parent 2 Name(if applicable)

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Parent 2 Phone Number

Please enter a valid phone number.

Spouse (if applicable)

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.

Emergency Contact

Emergency Contact Name

First NameLast Name

Relation to Applicant

Emergency Contact Phone Number

Please enter a valid phone number.

What are your reason for applying to Set Free Ministries Recovery Center

Are You willing to commit to a 6month program

yesno

Who will pay for your recovery program until you find employment

First NameLast Name

Phone Number

Please enter a valid phone number.

While in the Recovery Center who will receive reports on your recovery

First NameLast Name

Phone Number

Please enter a valid phone number.

Medical History

Have you recently been in a treatment program? If so, please provide details.

Which substance(s) are you currently seeking recovery from?

Will you need to detox?

YesNo

How long have you been currently continuously sober? Example 12 days

Days Sober?

Can you climb stairs without difficulty?

YesNo

Can you read and write without difficulty?

YesNo

Do you currently have any diagnosed physical/mental health conditions? If yes, please provide details.

Are you currently on any over-the-counter or prescription medications? If yes, please provide details.

Do you have a history of harming yourself? Do you have a history of thoughts of harming yourself? If yes, please provide details.

Do you currently have suicidal thoughts? If yes, please provide details

Criminal History

Do you have a history of violent behavior? Do you have a history of having violent thoughts? If yes, please provide details.

Have you ever been convicted or arrested for a violent or sexual offense? If yes, please provide details.

Do you currently have any Emergency Protective Orders from/against any individuals?

Have you ever been to prison? If yes, please provide details of offense(s) and dates.

Are you currently on or expecting to be on probation or parole? If yes, please provide details in addition to your probation/parole officer's name and contact details.

Do you currently have any pending court appearances? If yes, please provide details.

Are you currently or expecting to have a court mandate to attend a long-term recovery program? If yes, please provide details.

Please let us know any other pertinent information.