APPLICATION Application For Residency Please feel out the attached form and email to staff@hedgehouse.org or print and send application by mail to: P.O. Box 622 Wynnewood, OK 73098 APPLICATION Application for Residency Full Name Date of Birth Social Security Number Phone Driver's License Number Expiration DOC # Probation Yes No Relationship Status Married / Separated Divorced Single Do you have minor children? Yes No If yes, how many and what ages? Are you a Native American? Yes No Do you have a CBID or citizenship card? Yes No Are you currently receiving disability? Employment What are your plans for employment? Do you own transportation? Yes No How do you plan to pay rent? Are you currently under a doctor's care? Yes No If yes, please explain Are you currently taking any prescription medications? Please list all meds, what they are prescribed for, and dosages Have you ever been diagnosed with depression, anxiety, or any other mental health issues? Have you completed a rehabilitation program? Please include dates and location Have you ever considered or attempted suicide? Please explain Do you engage in self harm? Please explain Tell us about yourself Why do you want to live at Hedge House? Hedge House is a Christ-based facility. Are you committed to following Christ and living as a committed Christian? What does being a Christian mean to you? (Required) * What do you consider to be your strengths? (Required) * What do you consider to be your weaknesses? (Required) * What are your short-term goals? (Next 6-12 months) (Required) * What are your long-term goals? (Next 1-5 years) (Required) * What motivates you? (Required) * How do you best receive love?* * What kind of work do you enjoy?* * What hobbies do you enjoy?* * What is your relationship like with your children, family, spouse?* * Additional Contact Information PO Name PO Phone Number DOC Name DOC Phone Number Case Manager Case Manager Phone Number Mental Health Provider Mental Health Provider Phone Number Primary Care Physician Primary Care Physician Phone Number Emergency Contacts Contact 1 Name Relation Phone Address Contact 2 Name Relation Relation Phone Address Contact 3 Name Relation Phone Address References Reference #1 Name Relation Phone Address Reference #2 Name Relation Phone Address Contract The design of Hedge House is to provide a hedge of prayer, protection, healing, and restoration around you and your recovery through a deepening relationship with Christ, godly counsel and mentorship, and likeminded Christian peers. Hedge House works optimally when every participant is dedicated to being a part of that hedge, ensuring safety for both yourself and others. Rules and a standard of conduct have been put in place to further your sobriety and protect your well-being. Hedge House will provide a safe place of support and love—our only goal is to see you succeed. Being accepted into Hedge House requires commitment from you to do your part to maintain the integrity of the hedge. Ecclesiastes 10:8 says, “He that digs a pit shall fall into it, and whoever breaks a hedge, a serpent shall bite.” We view hedging as a warfare technique, with the life and safety of each participant on the line. Are you willing to make that commitment? What ways do you feel you can contribute to the mission of Hedge House? By submission of this application, the applicant acknowledges that all information provided is true and complete and authorizes Hedge House to verify information and check references. Any false information permits Hedge House to deny application or be grounds for dismissal. Applicant acknowledges that this is application is for entry into a Christ based sober living facility that requires church and faith-based materials and curriculum. Applicant understands that this facility has a zero-tolerance policy on drugs, alcohol, and nicotine products. I agree Name * Date reCAPTCHA If you are human, leave this field blank. SUBMIT
