Courage House

Resident Application

Please complete all questions. This is a 9-18-month commitment that will require genuine effort from you. After completing the application, please call at Courage 812-887-9837 to schedule an appointment with the House Manager. You must bring your completed application to your appointment. If you are incarcerated or it is not possible for you to phone Courage, then please forward your application via mail 719 Busseron St, Vincennes, IN 47591, or email couragehouse2023@gmail.com. If there is not an immediate opening, then please call daily to demonstrate your willingness to participate in your own recovery. If the phone is not answered, leave a voice mail message.

Client Name:

Phone Number:

Address:

Have you had steady housing for the past 90 days?

Yes
No

Are you currently incarcerated?

Yes
No

If yes, when is your release date, or next court date?

Your Attorney Contact Information

Do you have any current or previous felonies?

Yes
No

If so, please list them below, please include the case numbers.

Do you have any sexual related charges? Currently or Previously?

Yes
No

Are you currently on Probation or Parole?

Yes
No

If yes, please provide Office Name, Contact Info, County, and State Below.

Length of Probation or Parole

Criminal History Authorization & Request Form

Have you ever been diagnosed with a mental illness?

Yes
No

If yes, explain.

Name of doctor who diagnosed you?

Date

SSN

Address

Date of Birth

Race

Sex

Drivers License/ ID Number

User Agreement

I am applying to be a resident of Courage House LLC. I understand and authorize Courage House LLC to perform a Criminal History Background Check. As part of the application process. I further acknowledge that on the application I have already disclosed all information that may be reported back on these reports. Checking this box acts as my electronic signature, which authorizes Courage House LLC to run a background check and contact your current parole/probation officer, or attorney.

Emergency Contact Information

Full Name

Relationship to You

Their Home Phone

Their Work Phone

Their Cell Phone

Their Home Address: City, State, Zip

We have prepared a few questions, complete honesty is needed in order for you to receive the proper treatment. Remember we are here to help not to judge.

1. What is your drug of choice?

2. What are your thoughts about starting this program?

3. What area in your life would you like or need to change?

4. Describe your past efforts to change. What happened?

5. Do you think you can do this on your own, or are you willing to ask others for help?

6. What do you want from other members of the house? Example: When I am messing up, I want someone to call me on it. I want straight, honest feedback.

7. What does honestly mean to you?

8.What does responsibility mean to you?

9. What does willingness mean to you?

10. What does open-mindedness mean to you?

11.What does humility mean to you?

12. What does gratitude mean to you?

13.How well do you know yourself? When you look into a mirror, who is the person you see? Not just from the outside but take a good look inside. What do you see?

14.What kind of person do you want to be?

15. Can you pass a drug screen? If not, are you detoxing?

16.What is different from you wanting to live in sobriety NOW than any other time?

17.What kind of Treatments have you been to? Were? What will be different this time? What have you learned from pass treatments?

18.You did everything out in the world to get high, are you willing to do whatever it takes to live a new clean and sober life?

19. Are you open to ideas to help you stay clean? Church, Bible study, 12 Steps, NA, AA, meetings things like that?

20. Are you willing to change everything you used to be? Even the old way you used to think?

21.What would you like to get from staying at the courage house?

22. Why are you ready to get sober and stay sober?

Agreement & Signature

Full Name (Electronic Signature)

User Agreement

By submitting this application, I affirm that the facts set forth in it are complete and true. I understand that if I am accepted, I must read Courage House LLC Policies and Procedures and agree to those entrance conditions.  I also agree to submit to drug/alcohol screenings or test anytime requested. All expenses owed to Courage House LLC must be paid on time. I will hold Courage House LLC and all Knox County free of all liability from fire, theft, personal injury while a resident of Courage House LLC.  Any false statements, omissions, other misrepresentations made by me on this application may result in my immediate dismissal.

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