Application for Membership into The RecoveryChick House

Hello Beautiful RecoveryChick,

We have been praying for you and we are glad you are here. You are not alone.

RecoveryChick's have been where you are and we are here to boldly proclaim people like us do recover!!

We are a breed of broken people who are in the process of being transformed. We are not ashamed to tell our story and not ashamed of Jesus. We are putting a purpose to our pain. We are sharing our lives with others so, they too can be free. When He sends us, we will go. We are applying recovery principles to every area of life, and living a life we never could've imagined. We are recovering from anything that’s keeping us from living our God-given purpose and destiny. We are stepping out of denial and into God's grace.

If this resonates in your Spirit and you are ready to do the honest work of recovery we invite you to fill out this application and come to live with us in this Christ-Centered recovery community.

“For I know the plans I have for you,” says the Lord.
“They are plans for good and not for
disaster, to give you a future and a hope.
— Jeremiah 29:11 Life Recovery Bible

Looking forward to meeting you,
Pastor Cynthia Corder
Founder, Executive Director

WELCOME TO JUDY'S HOUSE!


RecoveryChick sponsors a Christ-centered sober living, discipleship home called Judy’s House, located in Galveston, TX.

This program is for females who desire to allow God by the power of the Holy Spirit to change them into the women that God intended them to be and to be firmly established in the new life God has promised.

To be accepted into Judy's House, an applicant must fully complete this application and interview with one of our staff members. Acceptance into the house is based upon the approval of our staff and current house members.

Carefully read the application, and please answer honestly so we may know how best to help you. Living in the RecoveryChick House is special, and if you understand its value, it can help you achieve comfortable, consistent sobriety, without relapse. All information provided is kept confidential.

Fill out this form if you qualify:

• At least 30 days of continuous recovery
• Willingness and ability to work a Christ-centered program
• Not take any narcotic medications
• Ability and willingness to work and be trained in our work study program
• Women live in an upstairs unit. Must be able to walk upstairs.
• Pay $300 application fee, and pay rent each week (sponsorship's may be available for application fee, rent depends on which room you live in)

Please return this form to Cynthia@Recoverychick.com or RecoveryChick, 527 21st Street, #332, Galveston, TX 77551 Attn: Pastor Cynthia Corder

How Judy's House helped me: Dianna's Story.
How Did You Hear About Judy's House?
What Do You Know About Us?
What's Your Name *
First , middle, and last name
Your answer
Date of Birth *
MM
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Current Age
Your answer
TDCJ# (applicable)
Your answer
Current Address (Street, City, State, Zip)
Your answer
Last Permanent Address (If Homeless)
Your answer
Phone Number
Your answer
Are you a US Citizen?
If not a US Citizen are you a permanent resident?
Email *
Your answer
Have you ever been incarcerated?
If yes, list convictions.
Your answer
Have you been charged with anything requiring you to register as a sex offender?
Will you be or are you currently on probation or parole?
Do you know how long or what your requirements will be? If yes please explain
Your answer
Will you have an ankle monitor?
Do you have any pending charges against you?
If so please explain charges and include city and state of charges
Your answer
Marital Status *
Current Spouses Name (legal marriage only)
Your answer
Current Spouse Phone Number
Your answer
Please describe your support system-family or otherwise and include where they are located
Your answer
Do you have children? If so please list their names, ages and caregivers. Please note Judy's House cannot accept children as residents
Your answer
Have your parental rights been terminated?
What is the highest level of education completed?
If you have a college or career training please list degree, certification, or hours attended
Your answer
Did you receive your GED?
What year did you receive your GED
Your answer
Do you have any learning needs or problems? If yes please explain
Your answer
Please rate your reading skills
Please rate your writing skills
Are you currently employed? If yes where
Your answer
Please list employment history
Your answer
What employment skills do you have? Example: Cooking, driving, office, computer software
Your answer
Do you have any physical ailment, injury, or handicap that would prevent you from performing work related tasks, doing house chores, or duties? If so please explain
Your answer
Are you disabled? If so please explain
Your answer
Do you receive benefits?
Medical and Mental Health
Please tell us about your health.
Do you have any medical conditions that would prevent you from actively participating in the program? If yes please explain
Your answer
Please list any medical conditions including seizures, tuberculosis, HIV, tranfusions, ear problems, hepatitis, diabetes, etc.
Your answer
Are you currently being treated for mental health or an emotional disorder? If yes please explain (Judy's House is not equipped to provide professional mental or health services)
Your answer
Do you have any mental conditions or learning disabilities that would prevent you from participating in the program
Are you currently taking psychiatric medications? If yes please explain diagnosis.
Your answer
If you are not taking psychiatric medications did you take them in the past or anticipate future use?
Your answer
Do you smoke? (Judy's House is a non-smoking facility inside and outside we have a stop smoking program for you to enroll in before you move in?)
List any current medications you are taking and explain why
Your answer
Drug and Alcohol History (Be specific)
Are you an Alcoholic? *
Date of Last Drink? *
MM
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DD
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YYYY
Are you an addict? *
Date of last drug use? *
MM
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DD
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YYYY
When did you attend your last AA or NA meeting? *
MM
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How many AA/NA meetings you do attend each week? *
Your answer
Do you want to stop drinking alcohol and using addictive drugs? *
Do you agree to NOT use any drugs or alcohol while residing at Judy's House? (Judy's House is a drug free facility) *
Have you ever been to a treatment facility for alcoholism and/or drug addiction? If yes, please provide the treatment center information.
Your answer
Income and Insurance
Tell us about your income, support and insurance
Are you getting welfare, government assistance, or any non-job related income? *
Your answer
What is your current monthly income? *
Your answer
What do you expect your next month's income to be? *
Your answer
Do you have medical insurance? *
Spiritual Background
Judy's House is a Christian faith-based discipleship program. Tell us about your faith.
Do you have a personal relationship with Jesus Christ
Please share your personal testimony of your faith (Life story).
Your answer
What have you done while incarcerated/treatment or since your release to build your relationship with Christ. Explain and include bible studies, church attendance, etc.
Your answer
Do you have a denominational preference?
Please explain the importance of prayer and bible reading in your spiritual life.
Your answer
Why do you desire to make behavioral changes in your life based on a relationship with Jesus Christ?
Your answer
Please list any type of recovery, spiritual or training programs that you participated in the past. (While incarcerated/treatment and or upon release)
Your answer
Have you participated in Celebrate Recovery? If yes please let us know where and when.
Your answer
Are you a Celebrate Recovery graduate?
Are you willing to participate in Celebrate Recovery/Christ Centered Recovery?
Future Goals
What do you hope to do with your life now that you are in recovery and living for Christ?
Briefly tell us what your goals are for the future and how you hope to accomplish these goals examples include work, school, housing, family, etc. (We will help you achieve these goals!)
Your answer
Explain your current needs for transitional housing and what you hope to gain from your time at Judy's House? (license, GED, Recovery Coach, Etc.)
Your answer
Recovery Services
We utilize traditional recovery meetings with faith based living. During your time at Judy's House you will learn about the Bible and how to live a biblically moral life. In addition to this we strongly believe local AA and NA programs are vital to our ongoing recovery. We encourage regular attendance at meetings and expect you to work with a sponsor through he steps of AA and NA. We also provide you with a RecoveryChick Peer Coach who will help you remove barrers to your recovery. With this in mind, tell us about your recovery.
Do you have a Recovery Coach?
Have you ever lived in sober living?
If yes, tell us about your experience there.
Your answer
Did you successfully complete their program and leave on good terms?
If no, what happened in your words.
Your answer
Share your journey of recovery.
Your answer
I understand and acknowledge that any recovery services offered at Judy's House are exclusively Christ centered in nature and are not subject to licensure or regulation by the Texas Commission on Alcohol and Drug Abuse. This program offers only non-medical treatment and recovery methods such as prayer, Christian, 12-step study, moral guidance, spiritual counseling, and scriptural study.
Date of desired move into the Recovery Chick House? *
Please provide 3 emergency contacts. Include their names, relation to you, and phone numbers. *
Your answer
I realize that the RecoveryChick House to which I am applying for residency has been established in compliance with the conditions of section 2036 of the Federal Anti-Drug Abuse Act of 1988, P.L. 100-690, as amended, which provides that any federal money loaned to start the house requires the house residents to (A) prohibit all residents from using any alcohol or illegal drugs, (B) expel any resident who violates such prohibition, (C) equally share household expenses including the monthly lease payment, among all residents, and participate in democratic group decisions based on expulsion from the House.
In accepting these terms listed above, applicants exclude themselves from the normal due process afforded by local landlord-tenant laws. *
I have read all the material on this application form, including the limitations set forth from RecoveryChick and Judy's House. I have also answered each question honestly and want to achieve comfortable, consistent sobriety, and ultimately recovery from alcoholism and/or drug addiction without relapse.
Please type you full name below as a signature to the terms listed above. *
Your answer
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