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TCR Admission Application
Contact Information
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* Indicates required question
First Name
*
Your answer
Last Name
*
Your answer
Email Address
*
Your answer
Phone Number
*
Only numbers are allowed (no dashes, spaces or parenthesis)
Your answer
Is it ok to leave you a voicemail identifying TCR?
*
Yes
No
Address Line 1
*
Your answer
Address Line 2
Your answer
City
*
Your answer
State
*
Your answer
Zip Code (please put any 5 numbers if you live outside the States)
*
Your answer
Do you have a valid Driver's License?
*
Yes
No
Date of Birth
*
MM
/
DD
/
YYYY
Race/Ethnicity
Choose
White
Hispanic or Latino
Black or African American
Native American or American Indian
Asian / Pacific Islander
Prefer Not to Answer
Other
Language of choice
Arabic
English
No Preference/FLuent in both languages
Clear selection
Marital Status
*
Single
Married
Divorced
Widowed
Other:
Professional Skills
*
Please list skills you have developed throughout your professional/academic career.
Your answer
Name of Father Confessor
*
Your answer
Phone Number of Father Confessor
*
Only numbers are allowed (no dashes, spaces or parenthesis)
Your answer
Email of Father Confessor
Your answer
Name of Sponsor (responsible for monthly payment)
*
Your answer
Phone Number of Sponsor
*
Only numbers are allowed (no dashes, spaces or parenthesis)
Your answer
Email of Sponsor
*
Your answer
Sponsor's relationship to you
*
Your answer
What addictions are you currently struggling with?
*
Alcohol
Crack, Cocaine
Prescription Drug(s)
Non-Prescription Opiates
Hallucinogens
Food
Gambling
Heroin
Marijuana
Methamphetamine
Nicotine/Tobacco
Other:
Required
Date of latest use:
*
MM
/
DD
/
YYYY
Are you physically able to take care of yourself?
*
Yes
No
Are you currently receiving EBT (food stamps) benefits?
*
Yes
No
Have you ever visited TCR?
*
Yes
No
Are you capable of comprehending a program of recovery?
*
Yes
No
Are you willing and capable of committing to a 9-month program of recovery without any interruptions?
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Yes
No
Why do you want to join the program?
*
Your answer
How did you find out about this program?
*
Your answer
Are you a registered sex offender?
*
Yes
No
Do you have any pending court dates?
*
Yes
No
Are you on probation or parole?
*
Yes
No
Have you been tested for STDs, Hepatitis?
*
Yes
No
List your currently prescribed/over the counter medications.
*
Your answer
Do you have health insurance?
*
Yes
No
Name of healthcare provider
Your answer
Health insurance policy number
Your answer
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