Application – People Like Us Recovery Residence

Residential Application Form

Full Name

What do you prefer to be called?

What is your current telephone/contact number?

Do You have an email address?

If you are currently residing within a facility (jail, prison, hospital, detox unit), please indicate a contact person/case manager that we maycontact. If you are incarcerated, what is your release date, court date, or sentencing date?

Please enter an additional contact number
( for a family member, community supervision officer, etc.)

Are you currently incarcerated?

If YES, what is the name of the institution

What are the circumstances that lead to your referral?

Are you a sex offender?

Do you have medical insurance?

What is your living situation?

If you have a permanent mailing address, please provide it here.

Do you have any permanent form of Identification? If so, Please proved it here.

Do you have any children?

Do you have an active Child Protective Services case with the Georgia Department of Family and Children Services?

Are you currently employed? If so, please enter the name of your employer.

List Current Medications You Are Using.

Do you currently have any pending or past legal problems? If so, please list them here.

Has a court mandated you to treatment?

Note: I understand that any false information will be grounds for non-admission to or dismissal from the People Like Us residential program. I also understand that submitting this application does NOT guarantee entrance into the People Like Us residential program.

I hereby declare that all the information I have given in this application (survey) is true to the best of my knowledge.