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Anchored: 30 Day Application

Anchored: 30 Day Program Application

Application for Admission

PERSONAL INFORMATION

Name:

First Last

Date:

MM slash DD slash YYYY

Address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone:

Hospital Code if required:

Email:

Social Security Number:

Birthdate:

Race or Ethnic Origin:

Gender at birth:

Veteran:

Yes

No

Who referred you to The Lighthouse?

Have you been admitted to our program before?

Yes

No

If yes, date of last admittance:

Are you ready to commit to a biblically-based rehabilitation program?

Yes

No

If needed could you sleep on a top bunk?

Yes

No

RELATIONSHIPS

I am currently (check all that apply):

Single

Married

Divorced

Living with someone

Do you have kids?

Yes

No

If yes, where do they live?

Name of church (if any) that you currently attend:

Location:

Medical History

Have you ever struggled with anxiety or depression?

Yes

No

Have you ever considered or attempted suicide?

Yes

No

Have you ever struggled with any other psychological issues?

Yes

No

Have you ever struggled with recurring medical issues that require ongoing medical treatment?

Yes

No

Have you ever been diagnosed with a disability?

Yes

No

Are you taking any medications?

Yes

No

If yes, please list medication(s) below:

Are you currently using (MAT) Medicated Addiction Treatment?

Yes

No

LEGAL HISTORY

Have you ever been incarcerated?

Yes

No

Have you ever been convicted of a felony?

Yes

No

Do you currently have a warrant?

Yes

No

Have you ever been charged with a sexual offense?

Yes

No

Have you ever committed arson?

Yes

No

Are you involved with CPS or have to report to any agency other than parole or probation?

Yes

No

Probation/Parole officer's name (if applicable):

Address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone:

Fax number:

Addiction History

How old were you when you first used illegal drugs or alcohol?

When was the last time that you used illegal drugs or alcohol?

Do you struggle with any other addiction?

Have you ever been treated for addiction before?

Where?

When?

* The Lighthouse does not discriminate on the basis of age, race, gender, religion, or sexual preference.

An Intake fee of $200 will be collected with the application or at the interview before being placed into the 30-day program. Payment will be accepted as cash, check, money order, or credit card.

I have a need for financial assistance

Applications will be kept of file for 6 months.

Δ

Email: Jdenney@LHFW.org or Jbradley@LHFW.org

Mail: 3000 E. State Blvd., Fort Wayne, IN 46808

Phone: 260-255-6413

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