LIFE RECOVERY PROGRAM APPLICATION Name(Required) First Last Personal Contact Information (e-mail/phone number):(Required) Birth Date MM slash DD slash YYYY Who Referred You to Our Program? Last Residence (prior to being in jail/prison, if applicable): Number of Times You’ve Been Homeless in Last 5 Years: Program OverviewWe offer a free, Christian faith-based recovery program for men experiencing homelessness and addiction. You do not need to be a Christian to enter the program, but our teaching will come from a Christian perspective. Our program requires a minimum 10 month commitment. The program consists of daily classes made up of life skills like money management, career readiness, and healthy relationships, in addition to Bible classes, discipleship classes, and relapse prevention. Participants also spend 25 hours a week at our thrift store where they learn and practice valuable soft skills like showing up on time, conflict resolution, receiving constructive criticism, and team work. Men who complete 7 months of the program will begin working on finding a job and saving money. After 10 months, men may choose to stay and work on finding housing or go to school for an additional 9 months. Primarily we are looking for two qualities in a participant: Someone who is ready to work on their recovery and someone who can do the basics of the program. Men who feel they meet those qualities may apply. We are a drug, alcohol and nicotine-free program. A drug test will be required upon intake appointment. Men must be experiencing only minor detoxification. Why are you interested in our program?Marital Status Single Married Divorced Widowed Primary Language English Spanish Other Other Language Are you able to read full books in English? Yes No With some help Do you have children Yes No ChildrenNameAge Add RemoveEducationHighest grade completed (K-12): Last school attended: Do you have one of the following: GED High School Diploma Last College / Trade school attended: Units completed: Do you have a: Checking Account Savings Account Do you have any outstanding debt: Yes No If yes, what is the estimated amount: Legal HistoryHave you been convicted of any sexual or violent crimes?(Required) Yes No If so, what? Are You Currently on Probation?(Required) Yes No Name of probation officer: Probation Officer phone number:Do you have any pending legal issues?(Required) Yes No Are you a Registered Sex Offender?(Required) Yes No If yes please briefly explain: Have you ever been incarcerated?(Required) Yes No How many times: ListReasonLength Add RemoveAre you now or have you ever been affiliated with a gang?(Required) Yes No If yes, name of gang: What (if any) rehab programs have you joined in the past? How long were you there? Did you leave on good terms?Are you willing to commit to fully completing the 10 month program, even if your legal terms end sooner (If Applicable)?(Required) Yes No Are you willing and able to sit through hour-long classes and participate in a group setting?(Required) Yes No Medical HistoryDo you currently have medical insurance?(Required) Yes No If so, what type: Are you taking any medication prescribed by a doctor?(Required) Yes No ListMedicationDosage (strength times per day)Reason Add RemoveAre you seeing a doctor due to Behavioral/Mental Health reasons?(Required) Yes No If yes, please explain your mental or emotional health diagnosis:Have you recently seen a Psychiatrist or Psychologist?(Required) Yes No If yes, please explain reason:Are you taking medication related to Mental Health?(Required) Yes No If so, what are you taking:Do you have any significant or relevant medical issues?(Required) Yes No If yes please explainDo you smoke?(Required) Yes No If you smoke, are you willing and able to stop? Yes No Drug HistoryPlease answer for all substances used:Tobacco / TabacoYears Used / Años de UsoFrequency / FrecuenciaLast Used / Ultima vez usadaAlcohol / AlcoholYears Used / Años de UsoFrequency / FrecuenciaLast Used / Ultima vez usadaCrack / PiedraYears Used / Años de UsoFrequency / FrecuenciaLast Used / Ultima vez usadaMarijuana / MarihuanaYears Used / Años de UsoFrequency / FrecuenciaLast Used / Ultima vez usadaMeth / ClaboYears Used / Años de UsoFrequency / FrecuenciaLast Used / Ultima vez usadaSpeed / AcelerantesYears Used / Años de UsoFrequency / FrecuenciaLast Used / Ultima vez usadaIV Drugs / Drogas EndovenosasYears Used / Años de UsoFrequency / FrecuenciaLast Used / Ultima vez usadaPCP / PCPYears Used / Años de UsoFrequency / FrecuenciaLast Used / Ultima vez usadaPowder Cocaine / Cocaína de PolvoYears Used / Años de UsoFrequency / FrecuenciaLast Used / Ultima vez usadaOtherDrugYears Used / Años de UsoFrequency / FrecuenciaLast Used / Ultima vez usada Add RemoveCan you lift 40 pounds?(Required) Yes No Can you stand for 2 hours at a time sorting clothing?(Required) Yes No Can you climb into a bunk bed?(Required) Yes No Developing a stronger relationship with Jesus:(Required) Very Important Somewhat Important Not Important I’m Undecided Help with your addictive behavior:(Required) Very Important Somewhat Important Not Important I’m Undecided Healthy and stable place to live for 10 months:(Required) Very Important Somewhat Important Not Important I’m Undecided Classes on money management, computer skills and career development(Required) Very Important Somewhat Important Not Important I’m Undecided Working in our thrift store every day:(Required) Very Important Somewhat Important Not Important I’m Undecided Being randomly tested for drugs and alcohol:(Required) Very Important Somewhat Important Not Important I’m Undecided Satisfying legal obligations:(Required) Very Important Somewhat Important Not Important I’m Undecided Looking for employment and affordable housing:(Required) Very Important Somewhat Important Not Important I’m Undecided Spiritual InformationHow would you describe yourself spiritually:(Required)Do you attend church?(Required) Yes No Name of Church and Denomination: Are you willing to attend weekly Bible study and a Christian Church on Sundays?(Required) Yes No Thank you for providing this information. The next step will be an evaluation of your application. We have a waitlist that fluctuates determined by a number of factors. If you’re determined to be good fit for our program and your waitlist spot comes up, we will hold a spot for you while we work out details with a parole officer, public defender, or other contact. On average it takes about a month on our waitlist for a bed to become available.Signature
