Transitional Housing Application
FULL NAME
TODAY'S DATE
DATE OF BIRTH (DOB)
PHONE NUMBER
EMAIL
ADDRESS
DATE AVAILABLE TO MOVE IN
HOW LONG HAVE YOU BEEN SOBER?
MOST RECENT REHABILITATION PROGRAM ATTENDED: (If any)
PLEASE LIST ANY SUBSTANCES THAT YOU HAVE BEEN ADDICTED TO IN THE PAST:
SUBSTANCE
DATE LAST USED
SUBSTANCE
DATE LAST USED
SUBSTANCE
DATE LAST USED
Why should you be selected to our Sober Living Program?:
Please list 3 things below that you would like to change in your life with the help of God and this program.
EMPLOYER
EMAIL ADDRESS
PHONE NUMBER
ADDRESS
PAY
HOURLY
SALARY
JOB TITLE
RESPONSIBILITIES
FROM
TO
REASON FOR LEAVING
ARE YOU ABLE TO PAY THE ENTRY FEE OF $350? (This is your first two week’s rent)
YES
NO
PLEASE LIST CHARACTER REFERENCES BELOW:
FULL NAME
RELATIONSHIP
EMAIL
PHONE NUMBER
FULL NAME
RELATIONSHIP
EMAIL
PHONE NUMBER
ARE YOU A REGISTERED SEX OFFENDER?
YES
NO
ARE YOU ON PROBATION./PAROLE?
YES
NO
NAME OF YOUR PROBATION/PAROLE OFFICER:
PROBATION/PAROLE OFFICER PHONE NUMBER
ARE YOU CURRENTLY TAKING ANY PRESCRIPTION MEDICATIONS?
YES
NO
IF YES, PLEASE LIST THE NAMES, DOSES AND FREQUENCY:
I understand that Jericho Creek Ministries is not a detoxification facility:
YES
NO
I understand that Jericho Creek Ministries is not a medical program:
YES
NO
I understand that Jericho Creek Ministries does not pay for medication:
YES
NO
I understand that Jericho Creek Ministries is not a licensed treatment center and I waive my right to legal action against Jericho Creek Ministries, it’s staff or volunteers based on any counsel I receive.
YES
NO
I, the Applicant, certify that my answers are true and honest to the best of my knowledge. If this application leads to my being accepted into the program, I understand that any false or misleading information in my application or interview may result in my relationship with Jericho Creek Ministries being terminated.
YOUR DIGITAL SIGNATURE
TODAY'S DATE
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