Request edit access
Application for Our Recovery Residence
Answer all questions and include a phone number so we can call you back.
Sign in to Google
to save your progress.
Name of the person you're applying for and his relation to you.
If you're getting out of jail or rehab, what date do you need a place?
If there's no bed currently available, how long can you wait on the waiting list?
Applicant's Date of Birth
Address that you currently call "home."
Cocaine / Crack
Heroin / Fentanyl / Other Opiates
Thc / Marijuana
Spice / Synthetic Marijuana / Bath Salts
Antidepressants / Sleep narcotics
When is the last time you used drugs / drank alcohol?
Employer if any
How will you pay your program fee?
Tell us about current legal issues.
Will you be on probation, parole, electronic monitoring?
What prescription medications will you be bringing?
Do you have back problems, walking problems or other problems with mobility? How severe?
Common Symptoms of Covid-19 are a fever or loss of ability to smell / taste correctly. Have you recently experienced these symptoms?
What is your emergency contacts email?
Who should we update about your progress (along with phone number or email)?
Feel free to be honest and answer this question: What are your feelings about the fact that at Celebrate Freedom, you will be expected to go to church as part of your recovery program?
Do you have additional comments for us to consider?
A copy of your responses will be emailed to the address you provided.
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Terms of Service