Sanctuary House Prescreen

Sanctuary House is a Christ-Centered recovery residence where men discover hope, healing, and a fresh start through Jesus. It is a place of unity, accountability, discipleship, and growth. Residents commit to living sober, maintaining steady employment, and actively participating in Bible study, journaling, and recovery fellowship.

As a faith-based organization, we are committed to serving all individuals with compassion, dignity, and respect. We do not discriminate based on race, ethnicity, gender, sexual orientation, religion, disability, or any other characteristic. The information you provide will never be used to harm or exclude you. It is collected soley to help us understand you needs and provide the best possible care and support in alignment with our mission and values. Your responses are voluntary and will be kept strictly confidential.

Sex

Male Female

This address will receive a confirmation email

If approved, what is the earliest day you can start?

Marital Status

Single Married Separated Divorced Widowed

What is your sexual orientation?

Can you pass a drug test?

Yes No

Date of last use (if applicable)

Have you sucessfully completed a detox or residential treatment program in the past?

Yes No

Have you or someone you know ever stayed at Sanctuary House?

How did you hear about the program?

What is your religious/spiritual background?

Sanctuary House is a faith-based discipleship sober living program. Do you understand and agree to take part in a Christ-centered recovery environment?

Yes No

Are you willing to commit to living in a sober environment with accountability, house chores, and house rules?

Yes No

Do you understand this is a 12-month Christian program designed for spiritual growth, recovery, and discipleship?

Yes No

Are you willing to attend Bible studies, recovery meetings, and discipleship sessions as part of the program?

Yes No

Current Employment Status

Full-Time Part-Time Not Employed Disabled

If yes, where do you currently work, and what is your schedule?

How many hours per week do you work?

Do you recieve SSI or SSDI?

Yes No

Do you pay child support?

Yes No

Are you able to pay the $120 weekly bed fee?

Yes No

What is your highest level of education?

Are you currently enrolled in school?

Yes No

Do you have a birth certificate?

Do you have a social security card?

Do you have a drivers license?

Yes No

Do you have reliable transportation? *Sanctuary House does not provide transportation outside of church services and recovery events.

Yes No

If yes, what type (car, Rtec, etc.)

Have you ever been convicted of a violent crime?

Yes No

Have you ever been convicted of arson?

Yes No

Have you ever been convicted of a sexual assult?

Yes No

Have you ever been convicted of child abuse or neglect?

Yes No

Do you currently have any outstanding warrants?

Yes No

Do you currently have any pending court cases?

Yes No

If yes, where and when?

Are you currently on probation or parole?

Yes No

If yes, for what and where?

Do you have active Health insurance?

Yes No

Have you ever been diagnosed with a mental health condition?

Yes No

If yes, please specify:

Do you ever experince anger issues or have a history of violent behavior?

Yes No

Have you ever attempted suicide, or are you currently experincing suicidal thoughts?

Yes No

Have you ever practiced self harm?

Yes No

How do you feel today?

List current medications:

Please list any relivant past medical history/major surgeries

Do you require any special accommodations for a known disability?

How do you usually handle the stress of difficult situations?

How would you discribe your communication style with others?

What qualities do you most value in yourself and others?

Do you agree to abide by Sanctuary House rules and expectations?

Yes No

What is your primary reason for seeking resdiency at Sanctuary House?

I give Sanctuary House permission to obtain any of my legal, personal, academic, or helth information from the Kentucky Dept of Corrections, Drug Rehabilitation Centers, Health Care Providers, DCBS, Counseling Services, or any program of which I am enrolled.

Yes No

By submitting this application, you affirm all responses provided are truthful and accurate to the best of your knowledge. Any falsification, misrepresentation, or omission of information may result in immediate disqualifiacation from the application process and, if admitted, dismissal from the program.

Sanctuary House Prescreen

Description

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