Resident Application

Name

Name of person filling out the application

Email Address

Your Phone number

I Prefer to be contacted by (you may select multiple):

Email Phone Text

I agree to the Terms and conditions set by Journey 2 Freedom, and by providing my phone number, I agree to receiving texts from the facility.

What brings you here today?

Applying for Myself Applying on behalf of someone else

Applicant’s Name and contact information

Date of Birth

MM/DD/YYYY

Have you ever been to Journey 2 Freedom before, or any other recovery residence? If so, please provide the name, and let us know when? *

Will you be transferring from an institution?(required)

Correctional Facility Detox Residential Treatment N/A

Have you ever been convicted of any sex crimes in any state?(required)

Yes No

Are you willing to make a commitment to the guidelines an expectations of Journey 2 Freedom, including, but not limited to: getting a sponsor, working the 12 steps, sponsoring other individuals, and attending 90 meetings in 90 Days in the program of Alcoholics Anonymous? (required)

Yes No

Please list all Medications and amounts that you take:

If you are prescribed medications, are you able to administer without assistance?

Yes No

Are you taking medicated assisted treatment meds? (Suboxone, Methadone, Vivitrol)(required)

Yes No

Have you been diagnosed with any mental illness(required)

Yes No

Date of last use of any mind altering substance, legal or illegal.

MM/DD/YYYY

Do you have any known warrants anywhere in the U.S.?(required)

Yes No

Are you on fixed income?(required)

Yes No

Are you physically able to work full time upon intake?(required)

Yes No

Are you able to pay an intake fee and first week dues upon entrance? (this answer will not disqualify you for being considered for acceptance into our program)(required)

Yes No

Resident Application

Thank you for your response. ✨