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Entry Assessment Form

- Step 1 of 5

Name *

First

Last

Email *

Phone Number *

Date of Birth *

Gender

Male
Female

Contact Person Information

Please provide information for 2 individuals we can contact as references. These individuals should have direct knowledge of your current struggles and be willing to serve as a contact person for you while you are in the program.

Contact Person #1 Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone Number *

Contact Person #2 Name

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone Number

History/Background Information

Please provide a brief personal biography (include information regarding your current situation and any life history that has contributed to your situation)

Have you ever been in our recovery program? *

If yes, please explain reason for leaving

Are you willing to spend 12-18 months in residential recovery? *

Have you participated in any other recovery program? *

If yes, please list the program name and dates of attendance

Are you incarcerated? *

If yes, where are you incarcerated?

Have you ever been arrested? *

If yes, please list your arrest history

Have you ever been convicted of a sex offense? *

If yes, please explain the nature of the offense(s)

Do you have any longstanding health issues that concern you? *

If yes, please list any medications you are currently on and your reason for taking them

Do you have a history of mental health issues? *

If yes, please provide details of diagnosis, treatment, medication(s), and any inpatient hospital stays for mental health treatment

Are you pregnant? *

Are you disabled? *

Do you receive disability, SSI or any other funds from the government? *

If yes, please enter the amount of the funds you receive

Legal Information

Attorney Name

First

Last

Attorney Phone Number

PO Name

First

Last

PO Phone Number

Court Referral Officer Name

First

Last

Court Referral Officer Phone Number

Describe your substance abuse history (include details about your drug of choice and other substances you have abused in the past and/or currently)

Do you consider yourself an addict? *

Explain why you do or don't consider yourself an addict

Why do you want to participate in our program and what do you hope to accomplish while here?

Submission

I AGREE TO PAY A $500.00 INTAKE FEE. (IF YOU ARE UNABLE TO PAY THE $500 INTAKE FEE DUE TO FINANCIAL HARDSHIP AND WANT TO APPLY FOR A FEE WAIVER PLEASE CONTACT OUR OFFICE OR INCLUDE A LETTER DECSRIBING THE REASON YOU ARE UNABLE TO PAY). *

Yes, I agree

I AGREE THAT ALL INFORMATION ON THIS FORM IS TRUE AND COMPLETE.

Yes, I agree

Phone Interview

Once we receive your application, we will conduct a phone interview with the applicant prior to approval.

DOWNLOAD & PRINT APPLICATION

If the applicant is incarcerated or otherwise without Internet access, you will need to print the application, mail it to them, and have them directly mail us the application along with a letter explaining their current situation and why they would like to enter our program.

Mailing Address

P.O. Box 895, Foley, AL 36536

DOWNLOAD APPLICATION

About Us
Get Help
Thrift Shops
Get Involved
News
Shop
- Shop Our Swag
Contact
- Email Signup
2024 Luau
- 2024 Luau Registration
Apply
- Residential Application
Give