About
Residences
Tyler, TX
Gun Barrel City, TX
Mabank, TX
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Resources
Requirements
What to Bring
Contact
Apply
Application for Addiction and Alcoholism Recovery
Applicant Information
Applicant's Name
Date of Birth
phone number
Email Address
Stress Address
City
State
zipcode
DO YOU OWN A VEHICLE FOR DAILY USE?
Select One
Yes
No
DO YOU HAVE A VALID TEXAS DRIVERS LICENSE OR TEXAS ID?
Select One
Yes
No
DO YOU HAVE AN ORIGINAL SOCIAL SECURITY CARD?
Select One
Yes
No
DO YOU HAVE AN ORIGINAL OR CERTIFIED COPY OF BIRTH CERTIFICATE?
Select One
Yes
No
Do you believe in God?
Select One
Yes
No
Marital Status
Select One
Single
Married
Divorced
Separated
Widowed
EMERGENCY CONTACT #1
relationship
contact number
EMERGENCY CONTACT #2
relationship
contact number
EMERGENCY CONTACT #3
relationship
contact number
Criminal & Abuse History
Currently in Treatment or Facility?
Select One
Yes
No
Treatment/Facility Name
Contact Name
Contact Number
Do you have an alcohol problem?
Select One
Yes
No
Date of LAst Drink
Do you have a drug use problem?
Select One
Yes
No
Date of Last Use
Do you want to stop using/drinking?
Select One
Yes
No
How many recovery meetings do you attend?
List Your Drugs of Choice (Note: Marijuana, Kratom, K2 & Spice are considered drugs)
Medical Doctor Name
Medical Doctor Contact Number
Mental Health Professional Name
MENTAL HEALTH PROFESSIONAL NUMBER
Name of last treatment center/detox
number of times in treatment/detox
List all the medications you are currently prescribed
Are you on Probation or Parole?
Select One
Yes
No
if yes, List County
if yes, name of supervising officer
if yes, list applicable fees
Have you ever bern diagnosed of mental illness
Select One
Yes
No
Are you a Registered sex Offender?
Select One
Yes
No
Any Pending legal charges?
Select One
Yes
No
If yes, which county?
Criminal History (List Misdemeanor & Felony Convictions & respective county where occurred)
Can you move-in immediately?
Select One
Yes
No
If no, give the reason
Have you lived in a Recovery at Timber Trails House before?
if yes, list the house name
If yes, what was the reason of your departure?
N/A
Voluntary
Disruptive Behavior
Nonpayment of EES
Relapse
If yes, did you leave owing money?
N/A
Yes
No
If yes, amount you left owing:
Have you ever been to rehab?
Select One
Yes
No
IF YES, WHERE?
IF YES, HOW LONG?
If yes, how many times?
Have you ever stayed in Sober Living?
Select One
Yes
No
if yes, where?
If yes, how long?
If yes, how many times?
Employment History & Income
Are you employed full-time?
Select One
Yes
No
Employment monthly income $
ARE YOU RECEIVING OTHER INCOME?
Select One
Yes
No
OTHER MONTHLY INCOME $
Do you pay Child or Spousal Support?
Select One
Yes
No
If yes, how much per month $
Are you mentally & physically capable of working a full-time job?
Select One
Yes
No
Employment History (list job skills)
Agreement
Use this space to tell us relevant information related to your active addiction and recovery, including why you want to live here.
Recovery at Timber Trails is a 501(c)3 Non-Profit Organization and oversees three sober living residences: Dreamcatcher, Legacy House and Stepping Stones Cedar Creek. Our residences are not licensed nor are they required to be. We do not prescribe medications nor accept any resident on narcotic medications.
I understand there are physical, mental and health risks in recovery from alcohol and drug addiction and accept full responsibility for myself, my actions and my recovery. The results of my recovery and ongoing sobriety are ultimately up to me and me alone.
Full name
Signature
Date
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