• Freedom House

    Admissions Application

  • Thank you for your interest in coming to Freedom House. We would be honored to work with you on your recovery journey. We take the screening process seriously so please read all the information carefully and follow the steps below: 


    Step 1: Read all information and complete the entire application. You must fill all of the application out yourself. Please give as much detail as possible to prevent delay in your application process. 


    Step 2: If it is determined that we can adequately meet your needs in our program, someone will be in contact with you within two business days of receiving your application. You will then participate in a screening before you receive an admissions date.

  • Please answer all questions honestly. Please do not leave any blanks in your application. If a question is not applicable to you please put N/A next to it.

  • General Information:

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  • Financial Assistance:

  • Children:

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  • Family:

  • Addiction and other mental health issues can be caused by genetics. It is extremely important that we get as much information as possible about your family in order to best help you in your recovery process.

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  • Relationship Status:

    As you are probably very aware, your intimate relationships greatly effect your addiction. It is extremely important that we receive as much information as possible in order to best help you in your recovery process.

  • Education:

  • Employment History:

  • Personal/Medical History:

  • Current Medications:

    List all medications you are currently taking:
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  • Medical Treatment:

    List all hospitalizations, surgeries, or any other treatment that you have received below.
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  • Psychological Treatment:

    List all mental health treatment(s) you have received below.
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  • Substance Abuse Treatment:

    List all substance abuse treatment(s) you have received below.
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  • Personal/Medical History Continued:

    Have you ever had any problems or been diagnosed with any of the conditions below?
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  • Personal:

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  • Drug Use:


  • Substance Use:

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  • Legal Background:

  • Spiritual:

  • Personal Statement:

  • Please write a personal statement of no less than 100 words including the answers to all the following questions. First, how your drug use has effected your children, your education, your employment, your housing, your self esteem, and your relationships. Secondly, how would you describe your understanding about God? Lastly, why have you chosen to come to Freedom House?

  • Release For Admissions

    All matters relating to applicant records and information and considered confidential and are treated as such by the staff of Freedom House. Information regarding such matters cannot be given without the written consent of the applicant.

  • With this signature, I am stating that I have truthfully filled this application out myself. I have given all truthful information filling out this packet. I understand that if Freedom House determines I have not answered these questions truthfully or I have withheld information, it may be considered grounds for refusal to or dismissal from the program.

  • Clear
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  • Should be Empty: