Pre-Application Screening

click here to download Addiction Recovery brochure

 

Name:              ___________________________________________________________

Address:          ___________________________________________________________

                        ___________________________________________________________

Email:              ___________________________________________________________

Home Phone:  _______________________ Work Phone:    _______________________

Cell Phone:      _______________________  Marital Status _______________________

 

Have you ever been a resident at the Colony of Mercy?  Yes  No

If so, when?  _________________    Did you graduate?  Yes   No

 

Please answer a few preliminary questions to help us determine your eligibility for the
Colony of Mercy Program:

1.  Are you willing and able to commit to a minimum of 120 days?  Yes   No

2.  Are you able to pay the $240.00 Application Fee?  (do not send now, to be sent with application)     Yes   No

3.  Do you have any outstanding legal matters?   Yes   No

4.  Do you have any court dates scheduled?         Yes   No  

When?  __________  For what?  ________________

5.  Do you have any court issues waiting to be scheduled?    Yes   No

6.  Have you been court-ordered to a program?    Yes   No

7.  Are you on Probation or Parole?   Yes  No    Which?  _________

Probation/Parole officers contact information 

Name _______________________  Phone __________________

8.  Is going to a program a condition of your probation?   Yes   No

 

If you answered yes to #3-8 please explain

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Are you physically able to work?    Yes   No

If you have work restrictions please explain:  ___________________________________

________________________________________________________________________

 

Please list ALL medications you take and for what reason:

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

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Thanks so much for visiting with us. We want to make sure that we have communicated well. We are all family, and desire that you have all the information that you need.

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We are so glad you dropped in to visit with us. We look forward to serving you. You are always welcome at America's KESWICK – online or in person – you're family.

In His service,

the America's KESWICK Staff Family
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