APPLICATION

Please do not complete this application on behalf of someone else. The application should be completed by the person in need of services.

If the applicant receives assistance with completion, he must review and sign the form as his official submission.

Please fill out each section truthfully and without blanks.

Admissions

Contact Information
Name*
First Middle Last
Address*
Street Address Address Line 2 City State ZIP Code
Primary Phone Number*
Secondary Phone Number
Email*
Enter Email Confirm Email
Birth Date*
Age*
Gender
Driver's License/State ID Number*
State Issued*
License Type
Expiration Date*
MM slash DD slash YYYY
Status*
- Valid
- Suspended
- Expired
- Revoked
Emergency Contact
First Last
Relationship
Phone
Brief Questionnaire
How did you hear about us?
If other, let us know.*
Please be specific*
Do you have any pending legal matters?*
- Yes
- No
If yes, please explain.*
Note: Disclosure of legal matters is not necessarily a disqualifier for services!
Do you have healthcare insurance or Medicaid/Medicare?*
- Yes
- No
If yes, please explain.*
Can you conduct the following activities of daily living without assistance?
Select all that apply
- Stand
- Walk and carry 25-50 pounds
- Walk up to 1 mile
- Feed yourself
- Use the toilet and bathe/shower
- Manage any prescribed medication
Are you currently prescribed or taking medication(s) for any medical health conditions?*
- Yes
- No
If yes, please describe (name, dosage, etc.):*
Are you currently prescribed, are you currently taking, or do you need Psychotropic, mood stabilizer, anti-anxiety, and/or anti-depression medication?*
- Yes
- No
If yes, please describe (name, dosage, etc.):*
Have you been under the care of a medical doctor (including a Psychiatrist) or a Therapist within the last Six (6) months?*
- Yes
- No
If yes, please describe.*
Have you spent time in a controlled environment within the past year?*
(i.e.: jail, prison, hospital, treatment center, mental health facility, etc.)
- Yes
- No
If yes, please describe.*
Will you allow us to contact your previous treatment professionals by signing a Release of Information (ROI) form?*
- Yes
- No
- N/A
Program Information
Program Information Consent*
I understand the following aspects of the No Longer Bound Program:
• No Longer Bound is a 12-month residential, Regeneration Program for adult men.
• If accepted, residents must live on the No Longer Bound campus.
• Two (2) forms of identification must be presented at the time of admission.
• Residents must abstain from use of tobacco, alcohol, and drugs while in the Program. Nicotine patches must be approved by the Medical Director (after admission) and purchased at the expense of the resident.
• No Longer Bound is a Christ-centered and clinically based program.
• All Residents are assigned a Recovery Specialist and an individual therapist.
• During the resident’s first 30 days in this program, he is not allowed to call or communicate with family or friends.
• After 60 days in the program, approved visitors are allowed.
• Residents are required to participate in the weekly church service.
• Residents must serve in one of No Longer Bound’s vocational training environment.
• Working off campus is not allowed during the initial phases of the program.
• All residents must participate in groups, classes, clinical sessions, and other activities as assigned in their daily schedule.
• All residents must be mentally and socially capable of participating classroom and group environments.
Presenting Factors for Treatment
What type of addiction are you struggling with and for how long?*
Please respond with 3 to 4 sentences minimum.
Presenting Medical / Behavioral Factors
Do you have any medical, behavioral, or emotional issues requiring special attention?*
Please respond with 3 to 4 sentences minimum.
Why No Longer Bound?
What specific event prompted your decision to apply for the Regeneration Program at No Longer Bound?*
Please respond with 3 to 4 sentences minimum.
How would you overcome any temptation that you might have to leave this program before you have completed it?*
Please respond with 3 to 4 sentences minimum.
Review, Certify and Submit
Note: If accepted into No Longer Bound's program, we will assess your cognitive orientation and readiness to complete the admissions process when your arrive. Additional information will be included in your acceptance letter.
Consent*
I certify that by signing below (digital or handwritten) that the statements and information herein are true and correct to the best of my knowledge and belief. I hereby authorize the staff of No Longer Bound to investigate all statements or other information contained in this form and any attachments submitted with it. I am sober and of sound mind as I record the information contained in this form, and provide my signature voluntarily, having fully understood the conditions and consequences outlined in this agreement.
Applicant's Name*
Today's Date*
Month
Day
Year
CAPTCHA

APPLICATION

Please do not complete this application on behalf of someone else. The application should be completed by the person in need of services.

Admissions

Contact Information

Brief Questionnaire

Program Information

Presenting Factors for Treatment

Presenting Medical / Behavioral Factors

Why No Longer Bound?

Review, Certify and Submit

Program

ways to give

about us

contact us

Program

Ways to give

Contact us

About us