Recovery Participant Application

WOMEN'S APPLICATION (Part 1 of 2)
Your application to The Damascus Road Foundation has been broken down into two parts. Part 1 covers General information, Employment, and Treatment while Part 2 covers Finanical, Criminal and Legal History, and Health.

This is Part 1. Once you have completed Part 1 and submitted it, you will automatically be redirected to Part 2.

All required fields in Part 1 and Part 2 have an asterisk (*) next to them and must be answered in order for each part to be submiited. BOTH Part 1 and Part 2 must be completed and submited.
I understand I must complete and submit of BOTH Part 1 and Part 2 of this online application in order to be considered for housing at The Damascus Road Foundation.
To provide your profile picture, click on the "Take Photo" link below and follow the prompts.
Profile Picture
GENERAL INFORMATION
Legal First Name
Legal Middle Name
Last Name
Preferred Name (Nickname)
Date of Birth:

MonthDayYear
Date
Ethnicity
Expected release date

MonthDayYear
Date
Desired House
Your Current Address (Street Number and Name)
City / State / Zip
Your email address
I consent to receive email communications from The Damascus Road Foundation
Best phone number to reach you?
I consent to receive automated SMS messages from The Damascus Road Foundation
SMS is not a secure, encrypted communication method. Carries may store copies of these messages. Message frequency varies. Msg & data rates apply. Test STOP to cancel.
Preferred Communication Method
EMERGENCY CONTACTS

Give TWO emergency contacts we can reach by phone.
Emergency Contact #1
Emergency Contact #1 (Name)

First NameLast Name
Emergency Contact #1 (Phone Number)
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact #1 (Email Address)
example@example.com
Emergency Contact #1 (Relationship)
Emergency Contact #1 (Address)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact #1 (Additional Info)
Emergency Contact #2
Emergency Contact #2 (Name)

First NameLast Name
Emergency Contact #2 (Phone Number)
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact #2 (Email Address)
example@example.com
Emergency Contact #2 (Relationship)
Emergency Contact #2 (Address)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact #2 (Additional Info)
EMPLOYMENT
Employment Status
Employment Details / Present Employer
Occupation / Position
How Long
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Previous Employer
ADDITIONAL INFORMATION
Who referred you to us?
What is the problem that caused you to seek help at this time
How long has this been problem?
Do you believe you are addicted to alcohol or drugs?
Please explain
How long since you've used alcohol or drugs?
Your Sober Celebration Date

MonthDayYear
Date
What did you use?
Describe your pattern of drug & alcohol use in the last 60 days
What has been your drug of choice in the past?
How many times have you made a serious attempt to stay in recovery?
What's the longest period of time you've been able to stay in recovery?
What has been most helpful in your past recovery attempts?
TREATMENT INFORMATION
I fully understand that it is a condition of approval that I will willingly obtain a drug and alcohol assessment/evaluation from a local, reputable, state licensed Healthcare Provider within 14 days of arrival to The Damascus Road Foundation. I will also follow the resulting recommendations in regard to IOP, OP and/or Relapse Prevention.
Have you ever received alcoholism/ drug addiction treatment?
Preferred Recovery Program (like AA, NA, Celebrate Recovery, Refuge Recovery, SMART Recovery, etc.)
Please select one recovery program from the options provided.
Please list all the treatment programs you've been involved in, beginning with the most recent (Minimum of 1 required).
Treatment #1
Treatment Name
Level of Care
Point of Contact Name
Point of Contact Title
Point of Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Point of Contact Email
Referral Information
Discharge Date

MonthDayYear
Date
Recovery Process
Treatment #2
Treatment Name
Level of Care
Point of Contact Name
Point of Contact Title
Point of Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Referral Information
Discharge Date

MonthDayYear
Date
Recovery Process
Do you have a current 12-step sponsor?
Sponsor Name:
Sponsor Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Should be Empty:

WOMEN'S APPLICATION (Part 1 of 2)

GENERAL INFORMATION

EMERGENCY CONTACTS

EMPLOYMENT

ADDITIONAL INFORMATION

TREATMENT INFORMATION