Beacon House - Admissions
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ADMISSION REQUIREMENTS:

►Acknowledged Substance Abuse Problem

►Desire to change by working a program of Recovery

►Commitment to follow Beacon House rules and      expectation

►Ability to pay rent of $425.00 per month

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OUR LIGHT GUIDES
YOU HOME

ADMISSION PROCEDURES:

►Schedule an appointment for an interview by calling
    (317)-375-0326

►Incarcerated individuals; interviews may be completed via 3-Way phone call or by mail

►Once accepted, Beacon House will schedule a date/time for move-in.

 
 
 
 
 
 

Please submit the following application if you are interested in becoming a resident at Beacon House. (Please remember that we also need a current criminal history report, as well as any current charges, included along with each appliction. Please fax criminal history reports to us @ (317) 375-1495)

The fields marked with (*) are required fields.

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Todays Date:
 * required

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First Name:
 * required

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Middle Name:
 * required

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Last Name:
 * required

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Address:
 * required

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City:
 * required

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State:
 * required

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Zip Code:
 * required

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Telephone Number:
 * required

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Age:

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Sex:

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Martial Status

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Date of Birth:
 * required

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Social Security Number:
 * required

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Emergency Contact Information: Please include name, phone number, relation to you.

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How where you referred to Beacon House:

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Why do you want to come to Beacon House?

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List all sources of income: Please include current employement, retirement and/or disability income.

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List all current medications:

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Are you allergic to anything?

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List Drugs of Choices: Please include length of time using each.

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What are your triggers to relapse?
 
List Current Treatment:
 
If currently in treatment please list name and phone number of case manager:

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List previous treatment and or halfway houses:

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Do you have any current legal situation? (ie. Pending Charge, on Probation/ Parole?)
Yes
No

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Please list the name state,county and phone number of your probation/ parole officer.

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What is your attorney's name address and phone/ fax number?

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Please list all arrest, convictions with the state, county, year and court number.