Application for Journey House - Hood River Alliance Church

Your name *

Email address *

Phone number

Address

Emergency Contact name and phone number *

Have you or are you currently part of inpatient or outpatient addiction treatment? *

What substance(s) are you in recovery from? *

Are you involved in Drug Court? *

Have you been convicted of a violent crime? *

Violent crime is composed of four offenses: murder and nonnegligent manslaughter, forcible rape, robbery, and aggravated assault. Violent crimes are defined as those offenses which involve force or threat of force. The key elements that classify an act as a violent crime include the use of physical force, intent to harm, and the presence of a victim who suffers physical or psychological injury.

Yes

Have you been convicted of a sexual crime?

Yes

List felony convictions, if any: *

List misdemeanor convictions, if any: *

Were you under the influence of drugs/alcohol when you committed the crime? *

Are you currently incarcerated? *

When released will you be on Probation or Parole?

Are you currently on Probation? *

Are you currently on Parole?

Do you have a case manager? *

Are you currently employed *

How will you pay your house dues? *

Medication List: *

Please list all medications you are currently prescribed, the dosage, and the reason they are prescribed.

Are you a part of Mental Health Court

Have you ever been admitted to a psych ward? *

When were you admitted to a psych ward?

What was the name of the facility?

Do you have a mental health team? (check all that apply) *

Psychiatrist

Psychologist

Therapist

Other

To which clinics have you gone for mental health services?

What medications did they prescribe?

How long did you take them? Or all you still taking them? If not, why did you stop taking the prescribed medication?

How long were you seeing your mental health professional?

What did they think was going on?

Do you agree?

Yes

Does this contribute to your addiction?

Yes

Other

How often do you see your doctor regarding your meds?

Please provide 2 references with contact information

Check each box below signifying that you understand and agree to meet the following expectations, if accepted for residency into Journey House. *

I agree to remain clean and sober at all times

I agree to pay my guest dues on time

I agree to keep Journey House free from alcohol, marajuana, and illegal drugs at all times

I agree to follow all guest rules for structure and accountability

I certify that ALL information I have provided to Journey House is true and correct. *

I have read all the material on this application form including the limitations above. I have answered each question honestly and want to achieve long-term sobriety from alcoholism and/or drug addiction.

I do

Type your name signifying a signature along with today's date *