Bridge House Recovery Residence Application

Bridge House Recovery Residence Application

Apply for admission to Bridge House Recovery Residence. Complete all required sections.
Applicant Information
Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email Address*
example@example.com
Current Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Social Security Number
Bridge House Location*

St. Charles (Men’s House)North County (Men’s House)St. Peters (Women’s House)Louisiana Missouri (Women’s House)
Emergency Contact Information
Emergency Contact Name*

First NameLast Name
Relationship to Applicant*
Emergency Contact Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Email (optional)
example@example.com
What is your current living situation*
Referral Source
Referral Source*

Treatment CenterProbation/ParoleDrug CourtSelf/FamilyOther
If 'Other', please specify
Recovery History
Primary Substances Used*
Date of Last Use*

MonthDayYear
Date
Treatment History (list programs and dates)*
Do you currently attend recovery meetings?*

YesNo
If yes, which meetings do you attend and how often?
Do you have a sponsor?*

YesNo
Medical and Mental Health
Do you have any medical or mental health conditions?*
Current Medications (list all)*
Allergies (if any)
Primary Care Physician Name
Legal Status
Are you currently on probation or parole?*

YesNo
If yes, Probation/Parole Officer Name and Contact Info
Do you have any pending legal charges?*

YesNo
If yes, please explain pending charges
Do you have a valid driver's license or acceptable ID

YesNo
Are you a registered sex offender?*

YesNo
Employment and Income
Employment Status*

Employed Full-TimeEmployed Part-TimeUnemployedStudentOther
Employer Name (if applicable)
Monthly Income (approximate)
Housing History
Describe your housing history for the past 2 years (include locations and dates)*
Program Commitment
I agree to maintain sobriety while residing at Bridge House (Initials)*
I agree to participate in drug and alcohol testing (Initials)*
I agree to attend required meetings (Initials)*
I agree to participate in household chores (Initials)*
I agree to follow all house rules (Initials)*
Faith-Based Program Acknowledgment
I acknowledge that Bridge House is a faith-based recovery program (Initials)*
Release of Information
I authorize Bridge House to obtain and release information as necessary for my participation (Initials)*
Applicant Certification
Date Signed*

MonthDayYear
Date
Should be Empty:

Bridge House Recovery Residence Application

Applicant Information

Emergency Contact Information

Referral Source

Recovery History

Medical and Mental Health

Legal Status

Employment and Income

Housing History

Program Commitment

Faith-Based Program Acknowledgment

Release of Information

Applicant Certification