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Application Submission

Resident handbook

The handbook is to be read in its entirety by the prospective resident before the application for residency is completed.

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- Step 1 of 18

I Acknowledge that I have read and understand the Covered Bridge Resident Handbook in its entirety. *

YES, I understand and agree to all terms and conditions of residency at The Covered Bridge.

Applicant Details

Name *

First

Middle

Last

Basic Info 1

Phone *

Phone Number

Date of Birth *

Race

Email Address *

SS#

Contact Preference *

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Place of Birth

City

State

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Previous Address

Address Line 1

Address Line 2

City

State

Zip Code

Family Background

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Mother's Name (if living)

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

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Father's Name (if living)

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Please list your brothers and sisters and their ages.

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Name 1

Name

Name 2

Name

Name 3

Name

Name 4

Name

Name 5

Name

Name 6

Name

Age 1

Age

Age 2

Age

Age 3

Age

Age 4

Age

Age 5

Age

Age 6

Age

Marital Status

Please Select Marital Status *

Single
Married
Separated
Divorced
Widowed

Marriage Date

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Date of Divorce or Separation

Reason for divorce or separation

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Spouse's Name

Name

Do you have any children?

Spouse's Phone

Please list your chidren and their ages

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Name 1-1

Name

Name 2-2

Name

Name 3-3

Name

Name 4-4

Name

Age 1-1

Age

Age 2-2

Age

Age 3-3

Age

Age 4-4

Age

Where are your children now?

Are you obligated to support dependents that aren't listed among your children.?

Please Choose

List all dependents that you are obligated to support that aren't listed among your children.

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Name 1-1-1

Name

Name 2-2-2

Name

Name 3-3-3

Name

Name 4-4-4

Name

Age 1-1-1

Age

Age 2-2-2

Age

Age 3-3-3

Age

Age 4-4-4

Age

List all relationships you have at present (girlfriends, fiancé, etc.)

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Name 1-1-1-1

Name

Name 2-2-2-2

Name

Name 3-3-3-3

Name

Name 4-4-4-4

Name

Age 1-1-1-1

Age

Age 2-2-2-2

Age

Age 3-3-3-3

Age

Age 4-4-4-4

Age

Medical and Health History

Have you been to a rehabilitation center before? *

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Location 1

Location

Location 2

Location

Location 3

Location

M/Y 1

Month/Year

M/Y 2

Month/Year

M/Y 3

Month/Year

Do you have and physical problems? *

If Yes, Please Explain

Are you currently on any medications? *

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Med 1

Medication Name

Med 2

Medication Name

Med 3

Medication Name

Med 4

Medication Name

Med 5

Medication Name

Reason 1

Reason

Reason 2

Reason

Reason 3

Reason

Reason 4

Reason

Reason 5

Reason

Have you taken medication for opiod dependancy?

Please explain in detail

Have you been or are you being treated for mental illness or emotional problems? *

Please give a detailed explanation

Alcohol and Drug History

Age you first used alcohol?

Age you first used drugs?

What was the drug?

Is there a history of alcohol or drug abuse in your family?

Approximately how long have you had a problem with drugs or alcohol?

Have you sought professional help before?

Have you ever attended AA or NA meetings?

Have you ever attempted to quit drinking or stop using in the past?

Have you have any success staying clean/sober?

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How Long 1

How Long?

How Long 2

How Long?

How Long 3

How Long?

When 1

When?

When 2

When?

When 3

When?

Medical & Drug History Continued

Please list all illegal drugs you've used, and the age when you first used each one

Have you abused any over-the-counter drugs, and if so what? and at what age?

What is your drug of choice?

When did you last use alcohol? *

When and what was the last drug you used? *

What are some LEGAL problems caused by your alcohol/drug use?

What are some MEDICAL/PSYCHIATRIC problems caused by your alcohol/drug use?

What are some WORK/SCHOOL problems caused by your alcohol/drug use?

What are some FRIEND problems caused by your alcohol/drug use?

What are some FAMILY problems caused by your alcohol/drug use?

Legal Information

Have you ever been arrested for, or accused of any sex or arson crimes? *

If yes, Explain in full:

Have you ever been arrested for other reasons? *

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List ALL crimes for which you have been arrested

CRIME

List ALL crimes for which you have been arrested2

CRIME

List ALL crimes for which you have been arrested3

CRIME

List ALL crimes for which you have been arrested4

CRIME

Status

Status 2

Status

Status 3

Status

Status 4

Status

Please List additional arrest information here

Are you currently incarcerated? *

Projected release date:

Are you/will you be under any state supervision? (IE. probation, furlough, or parole) *

If yes, Explain:

Do you have any pending legal cases? *

Explain any pending legal case(s):

Do you have ANY "No Contact" orders from the court or DOC? *

Please explain ALL "No Contact" orders:

How much TOTAL time have you spent in prision?

What program(s) will you likely be required to participate in as a condition of your release?

Job History

Where were you last employed?

What did you do there?

List any work skills and abilities that you have:

List and special job and/or vocational training that you've received:

Please list your job preferences:

Is there a job that you would like to do if you could receive the education/training required?

Religious Background

Denomination?

Church attendance per month

Did your family go to church when you were young?

Yes
No
Don't Remember

Have you been baptized?

Yes
No
Don't Know

Age Baptized:

Do you believe in God?

Yes
No
Don't know

Do you pray to God?

How often do you pray?

Do you read the Bible?

How often do you read the Bible?

Who is Jesus to you?

Religious Background Continued

Have you experienced any changes in your life spiritually?

What do you believe your problem is?

What have you done about it?

In what ways do you believe we can help you? *

What, if anything, do you fear?

As you see yourself, what kind of person are you? Describe yourself: *

Military History

Do you have past military service?

What branch?

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Discharge Date:

Discharge Type?

Education

High School - Highest Grade Completed? *

9
10
11
Graduated
GED
N/A

Did you attend college?

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Number of years

Did you graduate?

Area(s) of study / Majors and Minors / Diploma(s)

Other areas of education you wish to share

Personal References

Do you have a Pastor/Chaplain? *

Pastor/Chaplain Information

First

Last

Pastor/Chaplain Info

Pastor/Chaplain Phone

Phone Number

Pastor/Chaplain Email

Do you have a Caseworker? *

Caseworker Information

First

Last

Caseworker Info

Caseworker Phone Number

Phone Number

Caseworker Office Location

Office Location

Do you have a Probation Officer? *

Probation Officer Information

First

Last

Probation Officer's Info

Probation Officer Phone

Phone Number

Probation Office Location

Can we contact your previous employer?

Employment Info

Employer Name

Employer Phone

Phone Number

Personal References Continued

Reference 1 (other than a relative) *

First

Last

Reference 1

Reference 1 Phone

Phone Number

Reference 1 Email

Reference 1 Relationship

Relationship

Reference 2 (other than a relative)

First

Last

Reference 2

Reference 2 Phone

Phone Number

Reference 2 Email

Reference 2 Relationship

Relationship

Additional Info you would like us to consider?

I give permission to Covered Bridge to contact all references and person(s) listed in this application. *

I Agree

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Digital Signature *

Sign

Date *

Date