LIFE RECOVERY PROGRAM APPLICATION

Name(Required)

First Last

Personal Contact Information (e-mail/phone number):(Required)

Birth Date

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 Overview

We 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

With some help

Do you have children

Yes

Children

Name

Age

Education

Highest 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

If yes, what is the estimated amount:

Legal History

Have you been convicted of any sexual or violent crimes?(Required)

Yes

If so, what?

Are You Currently on Probation?(Required)

Yes

Name of probation officer:

Probation Officer phone number:

Do you have any pending legal issues?(Required)

Yes

Are you a Registered Sex Offender?(Required)

Yes

If yes please briefly explain:

Have you ever been incarcerated?(Required)

Yes

How many times:

List

Reason

Length

Are you now or have you ever been affiliated with a gang?(Required)

Yes

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

Are you willing and able to sit through hour-long classes and participate in a group setting?(Required)

Yes

Medical History

Do you currently have medical insurance?(Required)

Yes

If so, what type:

Are you taking any medication prescribed by a doctor?(Required)

Yes

List

Medication

Dosage (strength times per day)

Reason

Are you seeing a doctor due to Behavioral/Mental Health reasons?(Required)

Yes

If yes, please explain your mental or emotional health diagnosis:

Have you recently seen a Psychiatrist or Psychologist?(Required)

Yes

If yes, please explain reason:

Are you taking medication related to Mental Health?(Required)

Yes

If so, what are you taking:

Do you have any significant or relevant medical issues?(Required)

Yes

If yes please explain

Do you smoke?(Required)

Yes

If you smoke, are you willing and able to stop?

Yes

Drug History

Please answer for all substances used:

Tobacco / Tabaco

Years Used / Años de Uso

Frequency / Frecuencia

Last Used / Ultima vez usada

Alcohol / Alcohol

Years Used / Años de Uso

Frequency / Frecuencia

Last Used / Ultima vez usada

Crack / Piedra

Years Used / Años de Uso

Frequency / Frecuencia

Last Used / Ultima vez usada

Marijuana / Marihuana

Years Used / Años de Uso

Frequency / Frecuencia

Last Used / Ultima vez usada

Meth / Clabo

Years Used / Años de Uso

Frequency / Frecuencia

Last Used / Ultima vez usada

Speed / Acelerantes

Years Used / Años de Uso

Frequency / Frecuencia

Last Used / Ultima vez usada

IV Drugs / Drogas Endovenosas

Years Used / Años de Uso

Frequency / Frecuencia

Last Used / Ultima vez usada

PCP / PCP

Years Used / Años de Uso

Frequency / Frecuencia

Last Used / Ultima vez usada

Powder Cocaine / Cocaína de Polvo

Years Used / Años de Uso

Frequency / Frecuencia

Last Used / Ultima vez usada

Other

Drug

Years Used / Años de Uso

Frequency / Frecuencia

Last Used / Ultima vez usada

Can you lift 40 pounds?(Required)

Yes

Can you stand for 2 hours at a time sorting clothing?(Required)

Yes

Can you climb into a bunk bed?(Required)

Yes

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 Information

How would you describe yourself spiritually:(Required)

Do you attend church?(Required)

Yes

Name of Church and Denomination:

Are you willing to attend weekly Bible study and a Christian Church on Sundays?(Required)

Yes

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

LIFE RECOVERY PROGRAM APPLICATION

Program Overview

Education

Legal History

Medical History

Drug History

Spiritual Information

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Explore the RMA Family

Contact

Explore the RMA Family

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