Start the Journey to Recovery

To start the application process, please complete the Online Resident Application form below. To assist an expedited process, please download the Resident Application PDF, fill it out, and send it to [email protected]. Please note that completion of the online form, nor the more comprehensive download/email process does not in any way guarantee or reserve placement in our program.

Resident Application
File Size:	90 kb
File Type:	pdf

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Online Resident Application

Instructions
Please complete this entire form so that we may review your situation for consideration of admission to the program. All sections and questions are important to the overall qualification and review process. In the event there are items which cannot be answered, please enter “N/A” (not applicable) or “I have a question”. Please note that submission of an application does not in any way guarantee or reserve placement in our program. Additional information will be required to complete the application process.

Additional intake questionnaires will be required before consideration of acceptance in the program. To better understand additional information that will be required in the application process, please download and review the Resident Application (downloadable pdf form) that can be found at the top right of this page.

Questions: Please call us at (304) 239-1214.

Resident/Applicant Information

FYI - we are a gender specific program treating adult males.

* Indicates required field

Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Primary Phone *

Secondary Phone Number *

Email *

Family or Supportive Person Information

Name *

First

Last

Relationship *

Primary Phone Number *

Email *

Use History

Primary Substance(s) *

Amount/Frequency *

Date of Last Use *

Additional Comments *

Secondary Substance(s) *

Amount/Frequency *

Date of Last Use *

Additional Comments *

Background Information

1. Please summarize the applicant's treatment history *

2. Please summarize active addiction in the applicant's home/family (parents, siblings, etc.) *

3. Please summarize any additional behavioral health disorders *

4. Please summarize the applicant's legal/criminal history including pending or unresolved charges. *

5. Please summarize any/all psychiatric history, specifically addressing any suicidal or aggressive histories (define # attempts, most recent, etc.) *

6. Why are you interested in residence at the Jacob' Ladder recovery program? *

7. Has the applicant expressed a willingness to participate in the Jacob's Ladder recovery program? *

Yes No

Commitments and Requirements

Jacob’s Ladder at Brookside Farm, LLC (JLBF) requires active participation in a number of physically demanding scenarios. All residents are expected to participate fully in all program activities.

JLBF believes that unconditional positive regard for self, others and the earth is a critical element of successful program outcomes. Jacob’s Ladder will provide services to residents without regard to race, color, or national origin. All residents are expected to accept and carry forth that sentiment through their commitments, actions, words, and behaviors.

JLBF is a community of peers and other residents facing their challenges together. Though each situation is different and individually-customized, it is critical that all participants focus on their challenges without distracting others. All residents must comply with rules and regulations in order that they do not adversely affect the experience of others in the program.

Acknowledgements

By voluntarily submitting this application you acknowledge that there are general risks and dangers associated with a program of this nature; that the applicant has a personal desire and willingness to commit to the program, it’s schedule, it’s rules and requirements; that JLBF requires family participation according to program guidelines; and that the program is a minimum 6-months long.

Submit

Call Us Now! (304) 239-1214​

Start the Journey to Recovery

Online Resident Application

FYI - we are a gender specific program treating adult males.

Call Us Now! (304) 239-1214