Name of Applicant:
Referral Made By:
Referring Agency:
Current Residence:
Contact Phone:
How long have you been at current residence?:
When must you leave?:
How many times have you been to treatment?:
Date of Birth:
Age:
Race:
Marital Status:
Veteran:
Name of Nearest Living Relative:
Relationship:
Phone #:
Address:
Emergency Contact Person:
Relationship:
Phone #:
Address:
Please list any medical conditions/disabilities/psychological or psychiatric diagnosis:
Please list any prescribed medications, dosage and reason for taking:

If there are any diagnosed mental or physical disabilities, please upload documentation…this includes treatment for addiction. A doctor or other health professional must sign it.

Upload Documentation

Do you have a Tenn. Drivers License or State ID in your possession?:
Do you have your Social Security Card?:
Do you have your Birth Certficate?:
Employer:
Supervisor:
Phone:
Position:
Wages:
Number of Hours Worked:
Work Schedule:
Pay Schedule:
Please give a brief case history of the applicant and include the type of drug/alcohol use.
Why do you believe the person has made a sincere commitment to change and/or what have they done to improve their situation?
Is the person currently involved in any legal situations i.e. probation, pending litigation, court ordered requirements, etc?
Probation Officer Name (if applicable):
Probation Officer Phone Number (if applicable):
Does this person have access to transportation other than MTA?
If yes, what type of transportation?
Does the referring agency suggest any follow up or after care procedures?
If yes, please describe.
Does the applicant have a "sponsor"?
If so, please give name and phone number
How much money does the applicant have saved at time of application?
If less than $125.00, does the applicant have ability to pay first week's rent in advance?
Does applicant receive any other income such as Social Security, Disability, or other? Explain & give amounts.
What date does the applicant wish to move into the house?

By submitting this application form, applicant agrees this and other related information on this application may be shared with the staff of Welcome Home House.

CONSENT TO ABIDE BY GUIDELINES AND TERMINATION OF SERVICES

I have read the guidelines and understand them. My signature below indicates my willingness to follow these guidelines. I also agree to willingly submit to random drug testing. Refusal to take the test or a positive test will result in dismissal from the house and a forfeit of my $25 drug test deposit. However, if I test negative, my $25.00 drug test deposit will be refunded to me upon successful completion of the program. Furthermore, I agree to pay $125.00 per week, due on Friday of each week to the house manager along with other appropriate paperwork (Meeting sheets, AV sheets, Service Hours, Spending Plan, Employment Form, etc). I understand that failure to comply with any of these guidelines could result in dismissal from this program. Written notice will be given for reason of termination. The participant is given the opportunity to present written or oral objections before senior staff. Prompt written notice of the final decision will be given to the participant. It is also understood that any of my belongings left at the house will be discarded one week from my last day as a resident in the house. I agree to give notice to the house manager of my intentions to move out of the house (preferably two weeks.)

Please read the guidelines here (opens in new window) before signing and submitting the application.

Digital Signature (type your name):
Date: