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Name *

First

Last

DOB *

Address *

Home Phone

Cell Phone

have income? And

Email

SS# *

Age *

Race *

Sex *

Highest Grade Completed *

Martial Status *

Please write if you are Married, Separated, Divorced, Widowed, or Single

Do You Have Any children? yes or no *

If so how many?

Do you have any income? Yes or No *

If yes, describe.

Have you ever been a resident at 24/7 House Inc? Yes or No If Yes, when? * *

Do you have any medical problems that would prevent you from working? yes or No If Yes, explain. * *

Are you currently on ANY medications? Yes or No *

* Please list name of medications and dosage.

Are you on probation or parole? Yes or No If yes, explain. Name of Probation Officer Phone *

Have you ever been in a treatment program? Yes or No * If so, where? *

Have you ever attended AA/NA meetings? Yes or No * *

Denomination *

Drug(s) of Choice *

Last Used *

https://www.paypal.com/ncp/payment/WW8DEPWRJXSYY

Need to pay your admission fee, but can't come to Baxley? No worries, we are available online via PayPal to make things just a little less stressful. Copy our link to pay your admission fee.

Motivation Letter- Please write a letter stating your motivation for WHY you feel you are ready for RECOVERY. *

Who referred you to 24/7 House? *

Applicant Signature And Date *

Program Description

The resident lives in a Christ-centered, supportive community setting, which is alcohol/drug free. The 24/7 House, Inc. is a minimum 12-month program, but is not time based. Residents are required to follow ALL scheduled activities. Residents’ acceptance of responsibility for day-to-day living with other residents and participating in activities is a vital part of our program. Residents must be 18-years-of-age or older. The resident is required to be physically, mentally, emotionally and behaviorally capable of functioning in a residential setting and does not present a danger to himself/herself or others. After stabilization, as determined by staff, the resident is required to seek employment in order to meet the financial obligations necessary to remain in the program. The 24/7 House, Inc. will provide assistance in seeking employment, but it is the individual responsibility of the resident to find and obtain suitable employment. If the resident does not have gainful employment after the stabilization period the resident’s responsible party then assumes the financial obligation. All residents must be physically and mentally capable to maintain employment at all times. No refunds are given if a resident leaves or is discharged prior to completion.

What to Bring/NOT Bring

ITEMS TO BRING WITH YOU Picture ID Alarm Clock(NO clock radio) Social Security Card Work Boots Clothing for one week including church clothes Shoes, Casual and Recreational Sleepwear (Modest) Clothes Hangers (plastic only) Laundry Soap, fabric softener Laundry Bag or Basket Towel and Washcloth Personal Care Items (30 day supply) Approved medications (6 months of Refills) Paper, pens, pencils, envelopes, stamps Shower Shoes Hair Brush Hair Dryer Personal Hygiene Products Toothbrush Cigarettes (if you smoke) 60 Day supply ITEMS NOT TO BRING WITH YOU Items containing alcohol (as the first ingredient) Pipes Cards, dice or any games of chance Electronic/Entertainment equipment (TV, video games, laptops, PDA, etc.) Liquid Bleach Clothing that advertises bars, alcohol, drugs, gambling or offensive subjects No Sleeveless, spaghetti straps, or strapless tops, short shorts, or tight clothes Pornographic materials Cell Phones Personal CDs or DVDs Weapons of any kind Vehicle Reading Material Pictures

ADMISSION CRITERIA

Must be 18 years old or older Willing to commit to minimum of 18 month or successful completion Abstain from alcohol or drug use Legal matters will be discussed at application time Have no medical problems that would prevent resident from working Must be detoxed from all mood altering chemicals Will be interviewed by staff and be willing to participate in all activities and assignments Must have TB & HIV test Have NO contact with family and/or approved loved one for the first thirty (30) days Required to be physically, mentally, and emotionally capable of functioning in a residential setting Applicant does not present a danger to himself/herself or others Family will be required to participate in Family Day once a quarter and attend Al-Anon or Nar-Anon weekly. Applicant must disclose any criminal background before admitted into the program. If an applicant is dishonest about criminal history their stay in our program could be compromised.

Submit

FINAL-Admission-Application

To apply for admission into our program fill out the above application online and click Submit, or download the application and mail to :

Twentyfour 7 House                                                                                     

P.O. Box 354                                                                                                            

Baxley, GA 31515

ITEMS TO BRING WITH YOU

Picture ID                                                                                          Alarm Clock

Social Security Card                                                                        Pillow

Clothing for one week

Shoes, Casual and Recreational                                                  Work Boots

Sleepwear (Modest)

Clothes Hangers (plastic only)

Laundry Soap, fabric softener                                                     

Laundry Bag or Basket

Towel and Washcloth

Personal Care Items (30 day supply)

Approved medications (6 months of Refills)

Paper, pens, pencils, envelopes, stamps

Shower Shoes

Hair Brush

Hair Dryer

Personal Hygiene Products

Toothbrush

Cigarettes (if you smoke) 60 Day supply

ITEMS NOT TO BRING WITH YOU

Items containing alcohol (as the first ingredient)

Pipes

Cards, dice or any games of chance

Electronic/Entertainment equipment (TV, video games, laptops, PDA, etc.)

Liquid Bleach

Clothing that advertises bars, alcohol, drugs, gambling or offensive subjects

No Sleeveless, spaghetti straps, or strapless tops, short shorts, or tight clothes

Pornographic materials

Cell Phones

Personal CDs or DVDs

Weapons of any kind

Vehicle

Reading Material

Pictures

ADMISSION CRITERIA

1. Must be 18 years old or older
2. Willing to commit to minimum of 18 month or successful completion
3. Abstain from alcohol or drug use
4. Legal matters will be discussed at application time
5. Have no medical problems that would prevent resident from working
6. Must be detoxed from all mood altering chemicals
7. Will be interviewed by staff and be willing to participate in all activities and assignments
8. Must have TB & HIV test
9. Have NO contact with family and/or approved loved one for the first thirty (30) days
10. Required to be physically, mentally, and emotionally capable of functioning in a residential setting
11. Applicant does not present a danger to himself/herself or others
12. Family will be required to participate in Family Day once a quarter and attend Al-Anon or Nar-Anon weekly.
13. Applicant must disclose any criminal background before admitted into the program. If an applicant is dishonest about criminal history their stay in our program could be compromised.