Start the Journey to Recovery

Please either fill out the Online Resident Application form below in it's entirety OR download the Resident Application PDF, fill it out, and send it to info@jacobsladderbrookside.com.

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”.

Additional intake questionnaires will follow acceptance to the program.

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

Applicant Information

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

* Indicates required field

Name *

First

Last

Birth Date *

SSN (Social Security Number) *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Primary Phone *

Secondary Phone Number *

Email *

Shirt Size *

Shoe Size *

Guarantor Information

Name *

First

Last

Relationship *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Primary Phone Number *

Secondary Phone Number *

Email *

Family Information

MOTHER

Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Primary Phone Number *

Secondary Phone Number *

Email *

Stepfather Name (if applicable) *

FATHER

Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Primary Phone Number *

Secondary Phone Number *

Email *

Stepmother Name (if applicable) *

EMERGENCY CONTACT INFORMATION

Name *

First

Last

Relationship *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Primary Phone Number *

Secondary 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 *

Additional Substance(s) *

Amount/Frequency *

Date of Last Use *

Additional Comments *

Insurance Information

Policy Holder Name *

First

Last

Relationship to Applicant *

Policy Holder Date of Birth *

Policy Holder Employer *

Insurance Company Name *

ID # *

Group # *

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

Medical & Fitness Information

1. Please summarize any existing medical conditions. *

2. Please summarize any allergies. *

3. Please summarize current medical conditions. *

4. Please summarize special needs (deaf, blind, etc.) *

5. Please summarize any physical limitations to participating in an active farming environment or outdoor recreation programs. *

6. When was the applicant's last physical examination by a medical doctor? *

7. Are there any additional items you can share about the applicant's medical condition and overall fitness? *

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