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Lighthouse Application for Residence

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Please print out and send completed form to Lighthouse in Scranton, Inc. P. O. Box 199 Scranton, Pa 18504

 

Lighthouse Application

(Please print clearly)

 

  1. First and last name:    ___________________________________

 

  1. Mailing address:  _______________________________________

    _____________________________________________________

 

 

  1. Residence if different from above:  _________________________

 

 

 

  1. Your home and work phone numbers:  _______________________

    ______________________________________________________

    ______________________________________________________

 

  1. Persons to contact in case of emergency with phone number: 

 

            _______________________________________________________

 

            _______________________________________________________

 

            _______________________________________________________

 

            _______________________________________________________

 

  1. Your main reason for wanting to be part of the residential community at Lighthouse:  ________________________________________________

 

 

 

 

__________________________________________________________________

 

  1. Have you ever participated in any other form of counseling, recovery/healing programs before?  If so, what kinds and for how long a period?  __________

    ______________________________________________________________

    ______________________________________________________________

    ______________________________________________________________

 

 

  1. Have you ever received a mental health diagnosis?  If so, what was your diagnosis?  ________________________________________________

 

 

 

 

  1. Are you on any medications? If so, what kinds and what dosages?  __________________________________________________________________

 

 

 

 

 

 

  1. Are you working with a therapist now? If so, what is the purpose of your visits? 

 

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

 

  1. Why do you want to be part of the Lighthouse community? Please explain in details your motivation for wanting to come here:  _____________________

    ______________________________________________________________

    ______________________________________________________________

    ______________________________________________________________

    ______________________________________________________________

 

  1. What types of healing/recovery experiences have you had in the past? What modalities have helped you heal? E.g. spiritual means, therapy, support group friendships etc. Please explain your answer:  __________________________________________________________________

 

 

 

 

 

 

 

 

 

 

  1. How did you hear about Lighthouse?  __________________________________________________________________

    __________________________________________________________________

 

 

 

_________________________________________________________________

 

 

  1. Names and addresses and phone numbers of two persons who can give you a good reference:  ________________________________________________

    ______________________________________________________________

    ______________________________________________________________

    ______________________________________________________________

    ______________________________________________________________

 

 

 

(Following Section is for persons suffering from addictions to drugs and alcohol)

 

 

Please answer the following questions in detail if you have a drug or alcohol addiction.

 

  1. Are you acquainted with the twelve step programs?

 

          ___________________________________________________________________

 

  1. Are you addicted to drugs, alcohol, food, etc?  ____________________________

 

         ___________________________________________________________________

 

  1. If you are addicted to drugs or alcohol, how many days, weeks, months, years, do you have in continuous sobriety?  ______________________________________

 

 

  1. If you are addicted to drugs or alcohol, and are new in sobriety, ninety meetings in ninety days is required for you if you come to Lighthouse residential community.

 

  1. Are you willing do to do ninety meetings in ninety days upon arriving here? Yes/ No?

 

            Please explain if you answer is no:  ____________________________________

 

            _________________________________________________________________

 

            _________________________________________________________________

 

           __________________________________________________________________

 

          ___________________________________________________________________

 

          ___________________________________________________________________

 

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