Residential Recovery Program Application

Today's Date *

MM

DD

YYYY

Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Cell Phone *

(###)

###

####

Home Phone *

(###)

###

####

How did you hear about us? *

Web search

Social Media

Family/Friend

Former His Mansion Resident

His Mansion Presentation

Therapist/Counselor

Church

Other

Have you applied or were you a participant in the His Mansion Residential Program before? *

Yes

No

Marital Status *

Single

Engaged

Married

Widowed

Seperated

Divorced

Do you have children? *

Yes

No

Emergency Contact Name *

First Name

Last Name

Emergency Contact Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact Primary Phone *

(###)

###

####

Emergency Contact Secondary Phone

(###)

###

####

Do you have any medical conditions or health issues (e.g. Diabetes, heart problems etc.) *

Yes

No

Have you ever been diagnosed with a learning disability? *

Yes

No

Have you ever been diagnosed by a mental health professional? *

Yes

No

Are you currently taking prescription medications?

Yes

No

Have you ever been hospitalized for emotional or behavioral problems? *

Yes

No

Do you have any allergies? (e.g. Food, seasonal, animal, etc.) *

Yes

No

Is your diet restricted in any way? (Please note: Our program can only accommodate for gluten and dairy intolerances. We cannot accommodate a Vegetarian, Vegan, or similar diet.) *

Yes

No

Are you aware that the His Mansion Residential Program has a strong work component? *

Yes

No

Do you have any health problems that hinder you from doing physical work including heavy lifting? (e.g. Back injuries.) *

Yes

No

Are you court ordered to participate in a drug treatment program? *

Yes

No

Do you have any of the following that are pending *

Warrants

Court Dates/Appearances

Sentencing

Other

None

Are you on probation or parole *

Yes

No