Application for Membership into The RecoveryChick House

Hello Beautiful RecoveryChick,

We have been praying for you and we are glad you are here.  You are not alone.  

RecoveryChick's have been where you are and we are here to boldly proclaim people like us do recover!!  

We are a breed of broken people who are in the process of being transformed. We are not ashamed to tell our story and not ashamed of Jesus.  We are putting a purpose to our pain. We are sharing our lives with others so, they too can be free.  When He sends us, we will go. We are applying recovery principles to every area of life, and living a life we never could've imagined. We are recovering from anything that’s keeping us from living our God-given purpose and destiny. We are stepping out of denial and into God's grace.

If this resonates in your Spirit and you are ready to do the honest work of recovery we invite you to fill out this application and come to live with us in this Christ-Centered recovery community.  

“For I know the plans I have for you,” says the Lord.
“They are plans for good and not for
disaster, to give you a future and a hope.
— Jeremiah 29:11 Life Recovery Bible

Looking forward to meeting you,
Pastor Cynthia Corder
Founder, Executive Director

WELCOME TO JUDY'S HOUSE!


RecoveryChick sponsors a Christ-centered sober living, discipleship home called Judy’s House, located in Galveston, TX.

This program is for females who desire to allow God by the power of the Holy Spirit to change them into the women that God intended them to be and to be firmly established in the new life God has promised.

To be accepted into Judy's House, an applicant must fully complete this application and interview with one of our staff members. Acceptance into the house is based upon the approval of our staff and current house members.

Carefully read the application, and please answer honestly so we may know how best to help you. Living in the RecoveryChick House is special, and if you understand its value, it can help you achieve comfortable, consistent sobriety, without relapse. All information provided is kept confidential.  

Fill out this form if you qualify:

• At least 30 days of continuous recovery
• Willingness and ability to work a Christ-centered program
• Completely free of all mind altering substances and agree to random drug tests.
• Ability and willingness to attend groups and classes with a good attitude
• Physically able to attend groups and classes.  Must be able to walk upstairs.
• Pay $300 application fee, and pay dues each month/week.  ($540 a month or $150.00 a week)

Please return this form to Cynthia@Recoverychick.com or RecoveryChick, 527 21st Street, #332, Galveston, TX 77551 Attn: Pastor Cynthia Corder


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Email *
How Judy's House helped me: Dianna's Story.
How Did You Hear About Judy's House?
What do you know about Judy's House? *
What's Your Name *
First , middle, and last name
Date of Birth *
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Current Age
TDCJ# (applicable)
Current Address (Street, City, State, Zip)
Last Permanent Address (If Homeless)
Phone Number
Are you a US Citizen?
Clear selection
If not a US Citizen are you a permanent resident?
Clear selection
Email *
Spiritual Background
Judy's House is a Christian faith-based discipleship program.  Tell us about your faith.
Do you have a personal relationship with Jesus Christ
Clear selection
Please share your personal testimony of your faith (Life story).
What have you done while incarcerated/treatment or since your release to build your relationship with Christ. Explain and include bible studies, church attendance, etc.
Have you attended church or Bible Study program on a regular basis? Please explain and list.
If yes, please provide the name of the church or group and the contact person at the church (name and phone number).
Do you have a denominational/church preference?
Clear selection
Please explain the importance of prayer and Bible reading in your spiritual life.
Recovery/ Training/ Spiritual Programs
Please list any type of recovery, spiritual or training programs that you participated in while incarcerated/treatment and/or upon release.
Have you participated in Christ-centered Recovery (Celebrate Recovery) before and if yes, when?
Are you willing to participate in Christ Centered Recovery?
Clear selection
If you have been in a transitional/recovery house before, please provide the name of the facility and time period you were there.
Did you complete the program? What was your reason for leaving?
Future Goals
Briefly tell us what your goals are for the future and how you hope to accomplish these goals. Ex. work, school, dreams that have been set aside in active addiction. We want to help you achieve these!
Explain your current needs for transitional housing and what you hope to gain from your time at Judy's House.
Criminal Background
How many convictions have you had? What charges were you convicted of?
Have you ever been charged with anything requiring you to register as a sex offender?
Clear selection
What is your anticipated date of release?
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Will you be or are you currently on probation or parole?
Clear selection
Do you know how long or what your requirements will be? If yes please explain
Will you have an ankle monitor?
Clear selection
Do you have any pending charges against you?
Clear selection
If so please explain charges and include city and state of charges
Family Background
Marital Status *
Current Spouses Name (legal marriage only)
Current Spouse Phone Number
Current Spouse Address
How would you describe your relationship with your current spouse?
Clear selection
Please describe your support system-family or otherwise and include where they are located
Do you have children? If so please list their names, ages and caregivers. Please note Judy's House cannot accept children as residents
Educational Background
What is the highest level of education completed?
Clear selection
If you have a college or career training please list degree, certification, or hours attended
Did you receive your GED?
Clear selection
What year did you receive your GED
Employment Information
Please list employment history
What employment skills do you have? Example: Cooking, driving, office, computer software
Do you have any physical ailment, injury, or handicap that would prevent you from performing work related tasks, doing house chores, or duties? If so please explain
Are you disabled? If so please explain
Do you receive benefits?
Clear selection
Medical History
Please tell us about your health.
Do you have any medical conditions that would prevent you from actively participating in the program? If yes please explain
Please list any current medications you are taking and explain why.
Please list any medical conditions including seizures, tuberculosis, HIV, tranfusions, ear problems, hepatitis, diabetes, etc.
Mental Health
If you are currently being treated, or have been treated in the past, for a mental or emotional disorder and you do not disclose your information below, this could be grounds for dismissal. The RecoveryChick program is not equipped to proved professional mental or health services.
Are you currently being treated for mental health or an emotional disorder? If yes, please explain.
Do you have any mental conditions or learning disabilities that would prevent you from participating in the program
Clear selection
Are you currently taking psychiatric medications? If yes please explain diagnosis.
If you are not taking psychiatric medications did you take them in the past or anticipate future use?
Drug and Alcohol History (Be specific)
Which drugs/ alcohol have you used in the past and with what frequency?
Date of Last Drink? *
MM
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Date of last drug use? *
MM
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Do you agree to NOT use any drugs or alcohol while residing at Judy's House? (Judy's House is a drug free facility) *
Financial
How will you pay for your stay while at Judy's House? Please check all that apply:
If family or trust fund was chosen, please list names and phone numbers here:
Are you eligible for or receiving the following:
Recovery Services
I understand and acknowledge that any recovery services offered at Judy's House are exclusively Christ centered in nature and are not subject to licensure or  regulation by the Texas Commission on Alcohol and Drug Abuse. This program offers only non-medical treatment and recovery methods such as prayer, Christian, 12-step study, moral guidance, spiritual counseling, and scriptural study.
Clear selection
Date of desired move into the Recovery Chick House? *
I hereby authorize the release of information to RecoveryChick to receive the assistance I am requesting. I further certify that all the information on this application is true and correct. I understand that RecoveryChick may verify the information on this application and that deliberate misrepresentation of information my deny me acceptance to the program at RecoveryChick. I give RecoveryChick permission to discuss my case with other agencies, businesses, churches, attorneys, individuals, and any others deemed necessary to verify application information and/or identify additional sources of assistance. I understand that all information will remain as private as possible within these entities.
I realize that the RecoveryChick House to which I am applying for residency has been established in compliance with the conditions of section 2036 of the Federal Anti-Drug Abuse Act of 1988, P.L. 100-690, as amended, which provides that any federal money loaned to start the house requires the house residents to (A) prohibit all residents from using any alcohol or illegal drugs, (B) expel any resident who violates such prohibition, (C) equally share household expenses including the monthly lease payment, among all residents, and participate in democratic group decisions based on expulsion from the House.
In accepting these terms listed above, applicants exclude themselves from the normal due process afforded by local landlord-tenant laws. *
I have read all the material on this application form, including the limitations set forth from RecoveryChick and Judy's House. I have also answered each question honestly and want to achieve comfortable, consistent sobriety, and ultimately recovery from alcoholism and/or drug addiction without relapse.
Please type you full name below as a signature to the terms listed above. *
Please provide 3 emergency contacts. Include their names, relation to you, and phone numbers. *
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