Application For Project Rescue Addiction Recovery Program

Filling out and submitting this application starts the process of entering the Project Rescue Addiction Recovery Program.

We want to help you!

Please fill out this application, click the Submit button (at the bottom of this page) and the completed form will be forwarded to Ronnie Crocker.

Please call 256-616-1522 if you need help submitting the application.

The application process only takes 1 to 2 days.

After you submit this application, please call Ronnie Crocker at 256-616-1522 or email him at ronniecrocker1@gmail.com

Personal Information
Name:
Address:
City / State / Zip:
Home Phone:
Marital Status:
Age:
Birth Date:
Are you interested in the 1-Year Program or the 3.9 (three months in-house/nine months outpatient Program?
The 1-Year program.
The 3.9 Program.
 I need to hear about both programs.
Transportation Information
Do you currently have your own form of transportation? Yes No
Please Explain Your Alcohol & Drug Use Below:
Family Information
Parent’s or Wife’s Contact Information:
Phone:
How many children do you have?
Child’s Name Age Sex Mother’s Name

 

What type of work skills do you have?
Did you graduate high school?
Did you attend a university?
Do you have a drivers license?  Picture ID?
Do you have a social security card?
Do you receive government financial assistance?
Basic Needs Assessment:
 I need help with financial support for my first 3 months in the program.
 My family’s home congregation will provide financial support for my first 3 months in the program.
 My family will provide my financial support for my first 3 months in the program.
Transportation Information
Do you currently have your own form of transportation? Yes No
Please Explain Your Alcohol & Drug Use Below:
Drug Age Began Taking Amount Used Last 30 Days Last Time You Used It
Please Explain Your Criminal History Below:
Are you a registered sex offender?
Crime Date Convicted Time Served Date Released
Do you have a history of violence?
Additional Information:
Please give the name, phone number and minister of the church where your family attends:
Will you attend Bible Studies and church services?
Please list medications:
Please list any health issues:

 

Click the Submit button below and this application will be sent to Ronnie Crocker.

Call 256-616-1522 or email ronniecrocker1@gmail.com after you submit your application.