Apply - Miracle Recovery

Name

First

Last

Email *

Phone Number *

What type(s) of substance(s) do you struggle with? *

When was your last use, and which substances did you use at that time? *

Are you working right now? Work is a requirement for our program. *

Name and address of employer

How long have you worked there?

What is your salary and how many hours per week?

Do you have work lined up?

What type of work is it, and when do you start?

What will the salary be and how many hours per week?

Describe briefly plans for employment. If you are not capable of working 40 hours a week, please explain:

Current Monthly Income *

Do you receive other non-job related income/family support or welfare support? *

Please explain.

Marital Status *

Law Enforcement Involvement *

Current or Most Recent Charges

Have you ever been charged with any violent crimes or sex crimes? *

Explain in detail the charges and the situation(s):

Are you under a medical doctor’s care? *

The healthcare provider's name and phone number (or name of facility)

Current medications: *

Right now, are you under the care of a therapist, psychiatrist, counselor, or behavioral health facility? *

List all medical/psychiatric conditions you have been seen, prescribed medications, received surgery, or hospitalized for. *

Please enter their name, address, and phone number

What are you being seen for?

Do you have a sponsor or pastor? If yes, please type their name and telephone number:

Have you lived in a sober living environment in the last year? *

Did you leave voluntarily or were you asked to leave? Please explain.

Emergency Contact Name, Relationship, and Phone Number *

Checkboxes *

I understand that Miracle Recovery is a faith based recovery program for men. As a Christian program, church attendance, Bible Studies, and prayer meetings are attended in place of 12-step meetings.
I understand that Miracle Recovery has been established to promote recovery of alcoholism and drug abuse by: (A) prohibiting all residents from using any alcohol or illegal drugs, and (B) removing any resident who violates such prohibition. In accepting these terms, the applicant understands that these conditions are different than the normal due process afforded by local landlord-tenant laws and does not in any way constitute a landlord/tenant relationship. I also understand that the Company will run a background check on the information I provided and reserves the right to deny applicant if any information is deemed detrimental to the recovery of any individuals or if information provided in application is false.
By checking this box, I agree that I have read all of the material on this application form and have answered each question thoroughly and honestly. I want to achieve recovery from alcohol and/or drug abuse.