LifeHouse Guidelines

  • LifeHouse Guidelines

    Do not proceed with application before reading the following guidelines. LifeHouse is a one year program. Please do not apply if you cannot commit to this length of time.

  • For a printable PDF version of the form please click here

    • Any bills must be taken care of BEFORE entering the program. Most creditors will work with you if you notify them and let them know you are being admitted into a long-term residential program. Most creditors are happy to know that there will be restitution in the future. They are more than welcome to contact LifeHouse for verification.

    • There is no smoking, vaping or use of energy drinks while in the program.

    • Only your immediate family (father, mother, sister, brother, wife, and children only) and your Pastor and his/her spouse are allowed contact with you while you are in LifeHouse, unless specified by the Director.

    • You may not have contact with any previous boyfriends or past friends during your stay at LifeHouse unless specified by the Director.

    • You will not be allowed to have any male visitors (except immediate family) or date during the duration of the program unless specified by the Director.

    • You agree to participate in church, classes, work program, and program activities during your duration at LifeHouse.

    • All medications will be counted and locked up upon arrival and will be distributed as necessary.

    • You agree to refrain from discussing past experiences and medications with other residents.

    • If you decide to withdraw from the program (walk off) or if you are terminated from the program, LifeHouse will hold belongings for 72 hours and if not picked up, will be donated or discarded.

    • No cell phones are allowed until Phase 3 (minimum 4 months). If you bring one with you, it will be locked up until you reach Phase 3.

    • All money will be locked in LifeHouse’s safe and any money that is earned during your stay at LifeHouse will be divided into 4 categories: Tithe 10% (given to church), Savings 40% (which will be given to you when you leave), Rent 25%, Spending 25%. Spending will be distributed to each resident as needed and receipts must be submitted for the money that was spent.

    • All telephone privileges, pass privileges, and visits are privileges, not rights. You will receive such privileges based on your progression in the program.

    • All phone calls and letters are screened by staff for drugs, pornography, or deception.

    • If at any time during your program at LifeHouse you are not following our guidelines or rules, you may be asked to leave and have 24 hours to leave the premises.

    • You must bring a picture ID, social security card, and copy of your birth certificate.

  • I agree to the guidelines listed above.*
  • Date*
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  • LifeHouse Application

  • Personal Information

  • Date of Birth*
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  • Drivers License Status*
  • American Citizen*

  • Emergency Contact

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  • Who Referred You?

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  • Personality Information

  • Is it easy for you to express your feelings?*
  • Do you enjoy being with other people or would you rather be alone?*

  • Family History

  • *
  •  -
  • Has your father experienced any drug and/or alcohol abuse or mental health issues?*
  • *
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  • Has your mother experienced any drug and/or alcohol abuse or mental health issues?*
  • Were you raised by anyone other than your parents?*
  • How would you describe your relationship with your parents as a child?*
  • How would you describe your relationship with your parents at the present?*
  • Are your parents divorced?*
  • Have any of your siblings has any experience with drug/alcohol abuse or mental health issues?

  • Marital/Intimate Relationship History

  • Relationship Status*

  • Your present living arrangement*

  •  -
  • Do you have any children?*
  • Have you been sexually abused?*
  • Sexual Lifestyle*
  • Have you ever engaged in homosexual activities?

  • Legal History

  • Are you legally mandated to participate in a LifeHouse type program?*
  • If yes, by whom?

  • Are you currently or will you be under legal supervision?*
  • Method of Reporting

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  • Are any of the following pending?

  • Have you ever been arrested?*
  • Have you ever been in prison?*
  • If yes, date
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    • Arrest Records 
    • 1st Arrest Date
       - -
    • Convictions?
    • This charge involved
    • 2nd Arrest Date
       - -
    • Convictions?
    • This charge involved
    • 3rd Arrest Date
       - -
    • Convictions?
    • This charge involved
    • 4th Arrest Date
       - -
    • Convictions?
    • This charge involved
    • 5th Arrest Date
       - -
    • Convictions?
    • This charge involved
    • 6th Arrest Date
       - -
    • Convictions?
    • This charge involved

  • Social History

    Describe your involvement in the following:

  • Financial Status

  • Are you eligible for and/or receiving the following:

  • Have you ever applied for Food Stamps?*
  • Do you have any outstanding debts?*

  • Educational History

  • What is the highest grade that you have completed?*
  • Do you have*
  • Can you read?*
  • Reading Competency*
  • Can you write?*
  • Writing Competency*

  • Work History

  • What is your current employment status?*
  • Do you have any health related issues that would keep you from performing manual work related tasks while at LifeHouse?*
    • Previous Employment Information 
    • Employed Until:
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    • Employed Until:
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    • Employed Until:
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  • Medical History

  • Do you have any current medical issues?*
  • Do you have any current dental issues?*
  • Do you have any current mental health concerns?*
  • Do you have any dietary restrictions?*
  • Have you ever suffered from anorexia or bulimia?*
  • Are you currently suffering from anorexia and/or bulimia?*
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  • Do you suffer from mental health issues?*
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  • Do you smoke?*
  • Do you drink alcohol in access?*

  • Spiritual History

  • Do you have a personal relationship with Jesus Christ and are you born again?*
  • Did you go to church as a child?*

  • Have you ever been involved in any of these religious groups?

  • Have you ever been in any other program before?*
  • Should be Empty: