Life Recovery Home Application Life Recovery Home Application Name:* Date:* Address:* City:* State:* Zip Code:* Phone:* Hospital Code if required: Email Address: Social Security Number:* Birth Date:* Race or Ethnic Origin:*WhiteAfrican AmericanAsianNative AmericanIndianOtherGender:*MaleFemaleVeteran:* Yes No Who referred you to The Lighthouse?* Referral Address, Phone, 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 biblically-based rehabilitation program?* Yes No Are you currently working?* Yes No If yes, where? Are you currently receiving any income? Yes No If yes, from where? Did you complete High School? Yes No Do you have your G.E.D.? Yes No Do you have a college degree? Yes No Do you have reliable vehicle?* Yes No If needed could you sleep on a top bunk? Yes No I am currently:*SingleMarriedDivorcedLiving with someoneDoes your significant other drink alcohol or abuse drugs?* Yes No Do you have kids?* Yes No If yes, where do they live? Please list the names and ages of your kids:Name of church (if any) that you currently attend: Location: MEDICAL HISTORY Have you ever struggled with anxiety or depression?* Yes No Have you ever considered or attempted suicide?* Yes No Have you ever struggled with a personality disorder, bi-polar, or schizophrenia?* Yes No Have you ever struggled with any other psychological issues? 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 diagnosed with a disablility? 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 Are you take your medication as prescribed?* Yes No Are you currently using (MAT) Medicated Addiction Treatment? Yes No Do you have any allergies?* Yes No If you answered yes to any of the above questions, please explain:Are you currently incarcerated?* Yes No If yes, how do we contact you? Have you ever been convicted of a felony?* Yes No Do you currently have a warrant?* Yes No Are you involved with CPS or have to report to any agency other than parole or probation?* Yes No Have you ever been charged with a sexual offense?* Yes No Have you ever committed arson?* Yes No If you answered yes to any of the above questions, please explain:Please provide your probation or parole officer's name, address, phone, 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?* Have you lost a job because of an addiction?* Yes No Have you ever been treated for addiction before? Yes No If yes, where and when?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 or an opioid, the last time you used either, 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 them, quantity, and frequency:Please tell me about the first time that you abused prescriptions, the last time you abused them, quantity, and frequency:Please tell me about the first time that you viewed pornography, the last time you viewed 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:Please tell me about the first time that you abused synthetics (Spice, K2), the last time you used them, quantity, and frequency:Have you struggled with any other addiction? Please explain:I understand that The Lighthouse is a faith-based program and that as a result, I will be required to attend church services and participate in Bible studies and other faith-based recovery groups.* I agree I understand The Lighthouse is an alcohol, drug, and addiction free environment. I agree to stop participating in all 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.* I agree I agree to submit to all supervised urine screens and breathalyzers without question.* I agree I agree to pay all 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 all the information given on this application is true. 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 tell us about your childhood:*Please tell us about how you got involved in your addiction:*Please tell us about your religious experiences and your understanding of God:*Please explain what you have done so far to stay sober:*Please tell 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:*