Residential Application

First name

Last name

Phone

Email

Preferred Method of Contact:

Phone

Email

Are you currently taking any medications? If so, please list them:

Are you disabled or on disability? If yes, please explain

What life controlling issues are you struggling with that you think we could help you resolve?

What substances are you currently using and how often do you use them?

Have you ever been in any recovery/treatment program?

Yes

No

If so, where? How long did you attend, and did you complete?

Do you have any outstanding warrants?

Yes

No

Have you had any sexual or violent crime charges?

Yes

No

Are you willing to commit 12 months of your life to this program?

Yes

No

Are you willing to commit to our Christ centered discipleship program to help you overcome life's hurts, habits and hang-ups?

Yes

No

On a Scale of 1 to 10 how ready are you for a life change?

Is there anything else that you would like to say regarding your application?

What date would you like to enter The Summit?

Signature

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