Life Recovery Home Application Life Recovery Home Application Name:*Date:*Address:*City:*State:*Zip Code:*Phone:*Social Security Number:*Birth Date:*Age:*Race:*WhiteAfrican AmericanAsianNative AmericanIndianOtherGender:*MaleFemaleVeteran:* Yes No Who referred you to The Lighthouse?*Referral Address, Phone, Fax, and Email:Have you been admitted to our program before?* Yes No If yes, date of last admittance:Are you ready to commit to a 6-24 month, biblically-based, rehabilitation program?* Yes No Are you currently working?* Yes No If yes, where?Do you have reliable transportation?* Yes No Are you on Disability?* Yes No Tell me about your education:*Did not graduateGraduated High SchoolG.E.D.Some CollegeGraduated CollegeI am currently:*SingleMarriedDivorcedMarried but separatedLiving with someoneDoes your significant other drink alcohol or abuse drugs?* Yes No N/A Tell me about your parents:*They are both still livingBoth have passed awayOne is still livingDo you have kids?* Yes No Tell me about your kids:Do you attend church?* Yes No Tell me about your church:Have you ever struggled with anxiety or depression?* Yes No Have you ever attempted or considered suicide?* Yes No Have you ever struggled with a personality disorder, bi-polar, or schizophrenia?* Yes No Have you ever been diagnosed with HIV, HEP C, or another transmittable disease?* Yes No Have you ever struggled with recurring medical issues that require ongoing medical attention?* Yes No Have you ever been hospitalized for a major surgery or overdose?* Yes No Are you taking any medication? (Please list medication below)* Yes No Do you take your medication as prescribed?* Yes No Do you have any allergies?* Yes No If you answered yes to any of the above 9 questions, please explain:Are you currently incarcerated?* Yes No I soon will be Have you ever been convicted of a felony?* Yes No I soon will be Do you currently have a warrant?* Yes No I will soon Are you involved with CPS or have to report to any agency other than parole or probation?* Yes No I will soon Have you ever been charged with a sexual offense?* Yes No I soon will be Have you ever committed arson?* Yes No If you answered yes or I soon will to any of the above 6 questions, please explain:Please provide your probation or parole officer's name, address, phone, fax, and email contact information:How old were you when you first used illegal drugs or alcohol?*When was the last time that you used illegal drugs or alcohol?*How long have you known that you have an addiction problem?*Do you struggle with any other addiction?*How has your addiction affected your social activities?*Have you lost a job because of addiction?* Yes No If you have been treated for addiction before, please tell us about it: (Include name of agency, dates, and contact information if possible)Has addiction taken over more of your life than you had planned?* Yes No Please tell me about the first time that you used alcohol, the last time you used alcohol, quantity, and frequency:Please tell me about the first time that you used marijuana, the last time you used marijuana, quantity, and frequency:Please tell me about the first time that you used cocaine, the last time you used cocaine, quantity, and frequency:Please tell me about the first time that you used heroin, the last time you used it, quantity, and frequency:Please tell me about the first time that you used hallucinogens, the last time you used them, quantity, and frequency:Please tell me about the first time that you used amphetamines, the last time you used it, quantity, and frequency:Please tell me about the first time that you abused prescriptions, the last time you did it, quantity, and frequency:Please tell me about the first time that you viewed pornography, the last time you used it, quantity, and frequency:Please tell me about the first time that you had sex, the last time, and frequency:Please tell me about the first time that you struggled with an eating disorder, the last time you did, and frequency:Have you struggled with any other addiction? Please explain:I understand that The Lighthouse is a Christian program and that as a result, I will be required to attend church services and participate in Bible studies and other Christian-based recovery groups. I am open to allowing Christ to change my life.* I agree I understand The Lighthouse is an alcohol, drug, and addiction free environment. I agree to not participte in addictive behaviors while in the program. I understand that failure to do so may result in dismissal.* I agree I agree to follow the rules of the program and to submit to the authority of The Lighthouse and its staff.* I agree I agree to submit to all supervised urine screens and breathalyzers without question.* I agree I agree to pay program fees on time and as agreed upon during my intake.* I agree I understand that The Lighthouse is not responsible for any of my medical needs, transportation needs, or loss due to theft.* I agree I understand that a background check may be conducted.* I agree I authorize The Lighthouse staff to talk with my referral source, previous addiction providers, doctor, or lawyer to coordinate care.* I agree I acknowledge that, to the best of my knowledge, all the information given on this application is correct. I authorize investigation of all statements contained in my application. I further authorize The Lighthouse to speak with my support network to determine eligibility for admission. I authorize The Lighthouse to speak with anyone who may be representing me such as an attorney, or other legal representation, to assist in admission, recovery, and aftercare. I also agree that any false or misleading information could result in my not being accepted or in subsequent release from The Lighthouse.* I agree Please write a paragraph about your childhood:*Please write a paragraph about how you got involved in your addiction:*Please write a paragraph about your religious experiences and your understanding of God:*Please write a paragraph explaining what you have done so far to stay sober:*Please write a paragraph telling us why you want to be a part of The Lighthouse Program:*Please share anything else that you think we should know:Please type your name (digital signature) agreeing to the terms of this application:*