TreeHouse Application for Residence
Living at The TreeHouse will require studying Christian curriculum and spending time in a group Bible study. With the exception of going to pre-scheduled classes or appointments, you will exclusively spend your time at The TreeHouse.

You will surrender your cell phone, your electronic devices, any weapons, money card/debit card and food stamp card, plus all medication to the staff. TreeHouse staff or volunteers will make the necessary phone calls for you during the first 2 weeks of your stay. You will receive your mail after two weeks. We are a Tobacco Free residential ministry and you will be asked to sign an agreement that you will not use tobacco and will be subjected to random screenings for all substances.

Please answer the following questions honestly and to the best of your ability.
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First and Last Name *
Telephone Number *
Address *
How long at this address? *
Age *
Date of Birth *
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Marital Status *
Spouse/Significant Other Name
Spouse/SO Telephone Number
Spouse/SO Address
Spouse/SO Age
How long have you been together?
Do you have children together?
Počisti izbor
Names and Ages of Children
Emergency Contact Name (if different from Spouse/SO)
Emergency Contact Telephone Number (if different from Spouse/SO)
Emergency Contact Address (if different from Spouse/SO)
Emergency Contact Person's Relationship to You (if different from Spouse/SO)
When was the last time you spoke to your Spouse/SO/Emergency Contact? *
What brings you to seek admission to the TreeHouse? *
How long have you been dealing with this issue? *
Are there any other problems that seem to grow out of this one? *
What former help have you sought for this issue? (Check all you have tried.) *
Obvezno
Other methods you have tried? *
Are you aware that this ministry believes and teaches that with a personal relationship with Christ you can overcome your life-controlling problems? *
Have you committed your life to Jesus Christ? *
Are you aware that you will be taught per our interpretation of scripture and that we will not debate your religious beliefs or permit you to teach them to any other resident in the program(s)? *
In your own words, please describe what you think The TreeHouse is all about and what you think you will be doing while you are here. *
Do you have a driver’s license or state ID? *
State where ID was issued
Driver’s License or State ID#
Are you a US citizen? *
Do you receive disability income? *
What is the nature of your disability?
Do you have a court date pending? *
Nature of the charges:
Have you ever received a DUI or OVI? *
Other driving offenses:
Have you ever been convicted of a felony? *
Nature of convicted felonies:
Have you ever been convicted of any domestic violence charges? *
Are you a registered sex offender? *
If so, what tier and what county?
Do you have a parole/probation officer? *
Name of Parole/Probation Officer
Probation Officer Telephone Number
Do you have any pending warrants? *
If so, from what state and county?
Can you continue to stay in your current living condition for another month? *
Are you a veteran? *
Do you receive veteran's benefits? *
Have you been diagnosed with any communicable diseases (AIDS, Hepatitis, etc.) *
If so, describe:
When was the initial diagnosis?
What is the treatment plan?
Name of physician treating you for this illness
Current medications you are taking and dosages:
List any other health concerns.
Do you have any allergies? *
If so, describe:
Do you understand that The TreeHouse is not a licensed, professional drug/alcohol treatment program or a medical or mental health facility? *
The TreeHouse Handbook says, “The TreeHouse is not a medical facility and is unable to provide medical supervision. Therefore, you must be physically able to participate in every component of daily life and activities. If your health deteriorates to the point where you are no longer able to participate, or medical conditions require regular medical supervision, you must move out.” Do you understand that you must be physically able to participate? *
Do you understand that due to the nature of drug addiction you will very likely be around men with different communicable diseases? *
How long have you been clean and sober? *
Which substances are you currently addicted to? (Check all that apply.) *
Obvezno
Which substances have you been addicted to in the past? (Check all that apply.) *
Obvezno
What negative consequences have you experienced from drinking or drug usage? *
Do you ever have blackout periods of time that you are unable to account for? *
Do you experience any of the following? (check all that apply)
Please describe your experiences with any of the above.
Did you graduate high school or receive a GED? *
If not, what's the highest grade you completed?
Any college? If so, how far did you get in college?
Have you ever attempted suicide? *
If so, when? List all attempts.
Describe how you see yourself right now. *
Pošlji
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