Registration Application

Download the PDF and print HERE, or fill out the Application below:

This information is being collected for the use of God’s Way Home Inc. only.
Your confidentiality will not be disclosed to any other organization.
God’s Way Home, Inc. requires all potential residents to complete 7-10 days of detoxification and possess a certificate of completion of an inpatient 28-day program before entering our program.

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth

YYYY

Where have you lived the last 30 days?

Marital Status:

Highest Education

Are you permanently disabled?

Are you a veteran?

Current Employment

Last Employer

How did you come here seeking help?

Drug Information

How many times have you been treated for drugs and alcohol?

Most recent form of recovery?

What is the main substance(s) you are seeking to recover from?

Types of drugs you have used in the last 90 days:

Judicial Information:

Are you a sex offender?

What is your current legal situation if you have any?

Medical Information:

Are you currently taking any prescribed medications?

If yes, please list all prescribed medication you are currently taking.

Do you currently have any other medical conditions that we should know about?

Emergency Contact Information

Personal Information:

If you would like, please tell us a little bit about yourself and your story of how you got here today:

Once you've filled out the form, click submit below and your application will be sent directly and confidentially to us.