Application – Solus Christus

Full Legal Name

Street Address

City

State/Province

ZIP / Postal Code

Current Living Situation

Phone

Email Address

Date Of Birth

State or Country of Birth

Age

Height

Weight

Drivers License Number

State

Currently Valid?

What addictive substances have you ever used?

What substance did you last use?

When did you last use that substance?

Are you, or have you ever been an IV user?

How did you support your habit?

Do you smoke/vape?

What other addictive habits do you have?

Solus Christus is a smoke-free facility. No devices or products (vapes, gum, patches) containing nicotine are allowed. (We offer hard candy to help get through the cravings.)

Marital Status (single, married, separated, widowed, divorced, engaged, living together).

Husband's Name

Husband's Phone Number

How many children do you have?

Ages?

Who has custody of your children?

What child support issues do you have?

(If applicable) DSS worker name & #:

Reading ability

High School Graduate?

Education beyond High School?

Have you ever been a victim of the following?

Physical Abuse?YesNo

Verbal Abuse?YesNo

Emotional Abuse?YesNo

Sexual Abuse?YesNo

Ritual Abuse?YesNo

Have you ever been a victim of Rape?YesNo

Incest?YesNo

How old were you?

Have you ever been involved in prostitution?YesNo

Have you ever been involved in a same-sex relationship?YesNo

If so, when?

Are you a sex offender?YesNo

Have you ever attempted suicide?YesNo

If so, when and Why?

Have you ever self mutilated?YesNo

If so, when was the last time?

Do you or have you ever had a problem with food/eating?YesNo

Explain

What pending legal matters do you have?

Are you out on bond?

Are you on probation or parole?

Do you have an ankle monitor?

How much longer will you be on probation?

Attorney

Phone

Probation Officer

Phone

How much time have you spent in jail/prison?

Personal Reference

Phone

Church Reference

Phone

Church Denomination Preference

Are you open to going to a 12 month program?

When was your last medical examination?

Who did your medical tests?

Have you ever tested positive for TB, HIV, STDs, Hep C

Is there a possibility you are pregnant?

Current medical issues/diagnoses

What if any medications do you take? What are they prescribed for?

Do you have refills?

Past and present medical/psychological diagnoses

Do you have insurance?

If so, what kind?

Do you have allergies? (Food, Seasonal, Medications)

If so, what kind?

Are you able to perform the following tasks?

1) Housekeeping Chores (Vacuuming, mopping, laundry, dusting, cooking, cleaning, etc.)

2) Yard/Garden work (raking, hoeing, weeding, etc)

All bedrooms are on the second floor & we have bunkbeds. Is that a problem?

Solus Christus is unable to provide medical or convalescent care on-site and all residents must be physically able to participate in the program; any medical condition lasting for longer than a week preventing participation may result in discharge from the program.

Describe your relationship with Jesus Christ

Describe why you wish to come to Solus Christus

Please provide emergency contact information (Name, phone #, relation)

Solus Christus is a residential home providing temporary assistance to someone seeking long-term treatment for drug and/or alcohol addiction. While here, we help you find a program that is the best fit for you.

THIS IS NOT THE FINAL PROGRAM

Read the following statement before submitting: I have read this entire application and have provided truthful and accurate information about myself. I understand that my acceptance into the program requires a phone interview. I understand I may be dismissed from the program at any time if either my actions or my attitudes prove to be contrary to the rules. I give Solus Christus permission to use any pictures of me in publications for their ministry.

Solus Christus Online Application

Solus Christus is a smoke-free facility. No devices or products (vapes, gum, patches) containing nicotine are allowed. (We offer hard candy to help get through the cravings.)

Have you ever been a victim of the following?

Are you able to perform the following tasks?

Solus Christus is unable to provide medical or convalescent care on-site and all residents must be physically able to participate in the program; any medical condition lasting for longer than a week preventing participation may result in discharge from the program.

Solus Christus is a residential home providing temporary assistance to someone seeking long-term treatment for drug and/or alcohol addiction. While here, we help you find a program that is the best fit for you.

THIS IS NOT THE FINAL PROGRAM