• SECC 2026 Application

    Standard online application for Southeastern Carolina Crossroads (SECC). Follow the extracted DOCX field order and groupings as closely as possible.

  • Intake / Interview Info

  • Telephone Interview Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Do you know what Southeastern Carolina Crossroads is about?
  • Southeastern Carolina Crossroads is a faith-based drug & alcohol recovery ministry developed to help those who are ready to change their current lifestyle and break the bondage of addictions. We believe there is victory over addiction through a relationship with Jesus Christ and a Christian Walk guided by the truths of the Bible.
  • Have you been here before?

  • Personal Information

  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • High School Diploma or GED
  • Do you have a form of ID
  • Format: (000) 000-0000.

  • Reason for Applying / Substance Use

  • When was your last drink or drug?*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Are you subject to DT’s or seizures?

  • Marital / Legal Status

  • Do you have any court dates pending?*
  • Do you have a prior criminal record?*
  • Are you on parole or probation?*
  • Are you a convicted felon?*
  • Ever charged with child molestation or a sex offense?*
  • Ever convicted of manufacturing or soliciting illegal substances?*
  • History of repeated violent offenses?*

  • Program Terms & Fees

  • Do you have the $750.00 entry fee?*
  • Do you understand and agree to the 90-day program terms and restrictions on leaving?*
  • We expect all residents to make a firm commitment to complete our program. Residents will not be allowed to leave the premises for doctor's appointments, dentist appointments, attorney appointments or court dates. We will make every effort to assist in rescheduling any court dates. Only true medical emergencies will be accommodated.
  • Do you understand there will be no phone calls or visitation for the first 30 days?*
  • Do you agree to rules, guidelines, and daily work projects?*

  • Note: There are rules and guidelines we require all residents to observe, such as "No Tolerance rules." Infractions of such rules may result in immediate dismissal from the program. Also, you are required to participate in daily chores. These chores are designed to produce discipline, accountability and responsibility. They are not optional nor are they a source of income.

  • Health & Medical History

  • Are you disabled?*
  • When were you last hospitalized?
     - -
    2 digit month, 2 digit day, 4 digit year
  • When was your last physical exam?
     - -
    2 digit month, 2 digit day, 4 digit year
  • Was everything ok at last physical exam?
  • Ever diagnosed with Hepatitis?*
  • When diagnosed with Hepatitis?
     - -
    2 digit month, 2 digit day, 4 digit year
  • Is Hepatitis in remission?
  • Ever had TB?*
  • If yes, when did you have TB?
     - -
    2 digit month, 2 digit day, 4 digit year
  • Diagnosed conditions
  • Sexually Transmitted Diseases?*
  • Currently on or supposed to be on any medications?*
  • Are you taking any antibiotics?*
  • Any IV drug use?*

  • Final Commitment & Logistics

  • Do you still want to come?*
  • Do you have any questions?*
  • Do you accept the arrival terms (within 24 hours/as soon as possible)?*

  • Signatures

  • Applicant Signature Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Witness Signature Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: