Project Rescue

Addiction Recovery Program


Introduction   Staff  Cost  Rules 

Schedule  Facilities  Video    Application


Application For Project Rescue Recovery Program

P.O. Gox 1271
Hartselle, AL., 35640

The Project Rescue Recovery Program is a one year program conducted by Project Rescue, Inc. an Alabama non-profit corporation, primarily for individuals who need help in breaking addictive lifestyles. This program is generally administered in phases. To complete the program requires an intense class schedule, mandatory church attendance, and counseling sessions. Additional programs and individual counseling may be given based upon the needs of the individual.

The Project Rescue Recovery Program is faith based and Bible oriented at its core, and so the Bible will be the primary tool used to transform and heal lives. The Core Curriculum will be the NewLife Behavior courses. Please complete the Application and sign in all required areas. Your signature is your agreement to follow all rules and guidelines of the Project Rescue Recovery Program, should you be accepted into such.

Personal Information
Name:
Address:
City / State / Zip:
Home Phone:
Marital Status:
Age:
Gender:
Family Information
Do you live on your own or with family:
Family Contact Information:
Phone:
Were you raised by your natural parents? Yes No
Are both of your parents still alive? Yes No
How would you rate your childhood?
How many children do you have:
Child's Name Age Sex Mother's Name
If you don't live with your family who do you currently live with?
Live Alone
Live with Spouse
Live with partner other than spouse
Live with friends
Employment Information
What is your Employment status?
Unemployed, Looking for a job
Unemployed, not looking for a job
Part Time Employee
Working for family
Full Time Employee
What type of work skills do you have?
What is your work income $ /month
Other income $ /month
Who is your employer?
Employer Contact Information:
Phone:
Basic Needs Assessment:

Applicant is lacking the resources to provide for basic needs (food, shelter, clothing) and immediate assistance is needed;
Applicant has some resources to provide for basic needs, but has inadequate resources to totally be self sufficient financially;
Applicant has adequate resources to provide for all basic needs and costs.
Transportation Information
Do you currently have your own form of transportation? Yes No
What type? Bike Motorcycle Car Bus None
Primary Purpose for Seeking Assistance from Project Rescue Recovery Program:
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Criminal History
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Background Information:

The following information will become a part of your permanent file:

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Background Information:
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Religious Information:
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Referral

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Waiver of Liability

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Waiver of Confidentiality

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Cost Liability

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Additional Requirements

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