Resident Application Clone

Thanks for your interest in Reset.  If you haven't already, please take a moment to review our Policies and then complete the application form below. 

Requirements to apply:

At least 30 days of sobriety

Not on a MAT program (with the exception of Vivitrol)

Not be a sex offender

Have a sincere willingness to commit to our 9 to 18 month program

First Name

I have been sober for at least 30 days.

I am not on a MAT program with the exception of Vivitrol).

I am not a registered sex offender.

I am at least 21 years of age or older.

I am willing to commit to a 9-18 month program

I have read Reset's Policies.

Gender:

Date of Birth:

How did you hear about Reset?:

When would you be able to move in?:

What other programs have you contacted?:

Please list all convictions and dates.:

Terms of parole or probation (if any):

Do you have a significant other?:

Do you have children?:

If yes, where do they live now?:

Do you have any sources of income?:

What type of jobs have you done before?:

Have you ever served in the military?:

If you served, when were you discharged?:

Do you have any legal issues?:

If you have legal issues, please explain:

Please describe programs/recovery groups:

When did you last use alcohol or drugs?:

Substance type/amount used in last 24 hr:

Have you ever tried to stop before?:

Did you have any medical complications?:

Please explain any medical complications:

Have you ever been in treatment/detox?:

If yes, when & where?:

What is your primary drug addiction?:

Date of last use for primary addiction:

What is your secondary drug addiction?:

Date of last use for secondary addiction:

What age were you when you began using?:

Do you have any physical disabilities?:

If you have disabilities, please explain:

Are you taking any medications?:

If you are, please explain:

Please tell us your faith background.:

By submitting this application, you are authorizing Reset Ministries to contact authorities who are concerned with your welfare and housing, including, but not limited to, probation officers, social workers, and court officials.

Reset Ministries will use the information gained during the application process (this application, conversations with you, communications with involved authorities) in order to determine your eligibility for our program. Your personal information is kept confidential and will not be shared with anyone unless it is necessary in order to determine eligibility.