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Application for Our Recovery Residence
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Email *
Name of the person you're applying for and his relation to you.
Your Name *
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?
Phone number *
Applicant's Date of Birth
MM
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DD
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YYYY
Address that you currently call "home." *
Primary addictions
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.
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