Online Mini Application

ONLINE MINI-APPLICATION

You can either go to the Downloads Page and download and complete the entire application packet, or fill out this online form and we will mail you a packet.

Name:
Address:
Phone:
What is your Date of Birth? Month:
Day:
Year: (4 digit)
List your drugs of choice? Separate with commas:
What is your usual occupation?
Are you willing to stay in transitional housing for as long as it takes to get well?(AT LEAST 10 MONTHS)	YES NO
Are you OK with this being a faith-based home with Bible Study and Church REQUIRED?	YES NO
Are you on probation or have any pending legal problems?	YES NO
If YES, please explain:
Email Address:

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