Home of Recovery and Restoration Resident Application
New Resident Applicaiton
Email *
Home's Infromation
Physical Address: 6138 North State Highway 37 Winnsboro, Texas 75494
Mailing Address: PO Box 643 Winnsboro, Texas 75494
Home Phone: 903-347-1101
Note: Please read the "House Rules" before you begin your application.
Are you willing to abide by the House Rules?
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Full Name
Date
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Preferred Name
Address
Phone Number
Who referred you to the Home of Recovery and Restoration?
Church most recently attended?
Minister's Name
Minister's Number
Tuberculosis/ HIV Test
Emergency Contact
Fill out an emergency contact
Name
Relationship
Phone Number
Email
Personal Information
Date of Birth
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Place of Birth
Social Security Number
Drivers License Number
State
Expiration Date
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Is your license suspended?
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Height
Weight
Eye Color
What is your marital status?
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If you are married, state your wife's name
Do you have a current restraining court order?
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Do you have children
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Academic Information
Highest level of education?
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Are you currently enrolled in any kind of education program?
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If so, please state the name of the program.
Questions about your commitment
Are you willing to totally commit to an at least nine-month recovery and restoration program?
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Have you completed withdrawal?
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Are you willing to share in the daily chores here at the home?
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Are you willing to participate in work projects that the home might be involved in?
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Medical questions
List any current health issues and allergies that you may have
Do you take Prescription Medicine?
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If so, list each prescription
I understand that all my medication will be secured and only handed out at proper times and dosages by one of the Administrators?
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If you are currently receiving counseling, please state: Where, with whom, and for how long
Are you on a special diet prescribed by a Doctor?
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Please check any of the illnesses or symptoms you have experienced:
If you circled cancer, hepatitis or diabetes - please specify which type:
Approximately when was the last time that you had a physical exam by a medical doctor? State your doctors name and phone number.
Are there any medical conditions that you currently have or have had in the past that we need to know about?
Do you wear contact lenses?
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Glasses?
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Give date of your last eye exam.
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Are you currently experiencing any problems with your teeth?
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Do you wear any Dental bridges, mouth piece or dentures? If so specify.
Please check if you have had any in the past six months
Have you ever tried to commit suicide? When? Why?
Do you still have that tendency?
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Financial Information
Are you any kind of government financial assistance? If so, state which kind.
Do you know how your monthly resident fee here at the Home of Recovery and Restoration will be paid?
Do you have family members, friends, church affiliations that may sponsor you in your residency here?
Do you have any medical insurance?
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Miscellaneous Questions:
Do you have any trades like carpentry, welding, plumbing, ect...
List your Hobbies.
Would you like to learn a trade while you are a resident? If so, which one(s)?
Do you understand that you WILL NOT be given prescription medication to combat your addiction? If yes sign here.
If no, sign here.
I understand that I (the resident) will always ware proper shoes and clothing outside my room.
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I understand that I will be subject to random drug testing by the staff.
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I understand there are three levels of phone privileges and at any time (I) the resident can have the removed or given.
1. No phone
2. Phone will be given for work and turned in at night
3. Phone allowed on person
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I understand no resident can share their phone with another resident If it happens you will have phone privileges revoked.
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Last Information to Look Over

FACT: There is no natural escape from the addiction to drugs and/or alcohol. The only DESTINY for the addict is hard-time prison or a grave in the cemetery. Neither is very appealing! 

YOU MAY ASK: Who can deliver me from my addiction? 

ANSWER: JESUS CHRIST can deliver you from your addiction. 

JESUS CHRIST IS THE ONLY TRUE DELIVERER! You will be taught the Gospel of Christ in love. You will not be judged, condemned, or criticized by any of us. We want you to know that Jesus considered you worth dying for; therefore, you are precious in His eyes and the eyes of God the Father. 

We want to lead you to Christ so that you can be born-again in Him, and then we will fill your mind and heart with the Word of God. You will begin to develop a personal relationship with Christ and to mature spiritually in Him; and Christ working through your faith in Him will wash away your desire for drugs just like He will wash your sins away in His blood when you are born-again in Him. 

The Home of Recovery and Restoration Rehabilitation Program is a Christ centered home that welcomes men from all religions and spiritual backgrounds. Please be aware that while a man lives at the Home of Recovery and Restoration, he will be expected to participate in Bible studies and other Christian activities which are desperately needed and are highly effective in your healing process. 

IF you become a resident of the Home of Recovery and Restoration, we want you to graduate and go home as a new man in Christ, a new husband if your are married, a new father if you have children, a new son, a new grandson, and a fisher-of-men for Christ.

If you agree you have answered all the questions of this application correctly and completely. I have read the rules of this program and agree to comply with the rules and the staff of The Home of Recovery and Restoration Rehabilitation Program. I understand that if I have failed to answer questions on the application, or have not answered truthfully and completely, it may be considered grounds for refusal or dismissal from this program.

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