Application – Builder Site

P.O. Box 416
East Bend, NC 27018
Call us 336-813-3007

View Us on Facebook Visit our Instagram

Get Help

Donate

Home
Who We Are
How We Help
How You Can Help
Contact Us

Solus Christus Online Application

Full Legal Name

Street Address

City

State/Province

ZIP / Postal Code

Current Living Situation

Phone

Email Address

Date Of Birth

State or Country of Birth

Age

Height

Weight

Drivers License Number

State

Currently Valid?

What addictive substances have you used?

What did you last use?

When did you last use?

Are you an IV user?

How did you support your habit?

Do you smoke?

What other addictive habits do you have?

Solus Christus is a smoke-free facility. No devices or products (vapes, gum, patches) containing nicotine are allowed. (We offer hard candy to help get through the cravings.)

Marital Status (single, married, separated, widowed, divorced, engaged, living together).

Husband's Name

Husband's Phone Number

How many children do you have?

Ages?

Who has custody of your children?

What child support issues do you have?

(If applicable) DSS worker name & #:

Reading ability

High School Graduate?

Education beyond High School?

Have you ever been a victim of the following?

Physical Abuse?

Verbal Abuse?

Emotional Abuse?

Sexual Abuse?

Ritual Abuse?

Have you ever been a victim of Rape?

Incest?

How old were you?

Have you ever been involved in prostitution?

Lesbianism?

If so, when?

Are you a sex offender?

Have you ever attempted suicide?

If so, when and Why?

Have you ever self mutilated?

If so, when was the last time?

Do you or have you ever had a problem with food/eating?

Explain

What pending legal matters do you have?

Are you out on bond?

Are you on probation or parole?

Do you have an ankle monitor?

How much longer will you be on probation?

Attorney

Phone

Probation Officer

Phone

How much time have you spent in jail/prison?

Personal Reference

Phone

Church Reference

Phone

What Christian rehab are you looking at?

Have you ever been to a residential long-term rehab before?

Are you open to going to a 6-12 month program?

When was your last medical examination?

Who did your medical tests?

Dates of medical test's taken for TB, HIV, STD, HEP.C

Is there a possibility you are pregnant?

Current medical issues/diagnoses

What if any medications do you take? What are they prescribed for?

Do you have refills?

Past and present medical/psychological diagnoses

Do you have insurance?

Do you have allergies? (Food, Seasonal, Medications)

If so, what kind?

Are you able to perform the following tasks?

1) Housekeeping Chores (Vacuuming, mopping, laundry, dusting, cooking, cleaning, etc.)

2) Yard/Garden work (raking, hoeing, weeding, etc)

All bedrooms are on the second floor & we have bunkbeds. Is that a problem?

Solus Christus is unable to provide medical or convalescent care on-site and all residents must be physically able to participate in the program; any medical condition lasting for longer than a week preventing participation may result in discharge from the program.

Describe your relationship with Jesus Christ

Describe why you wish to come to Solus Christus

Please provide contact information

Solus Christus is a residential home providing temporary assistance to someone seeking long-term treatment for drug and/or alcohol addiction. While here, we help you find a program that is the best fit for you. This is not the final program.

Read the following statement before submitting: I have read this entire application and have provided truthful and accurate information about myself. I understand that my acceptance into the program requires an interview. I understand I may be dismissed from the program at any time if either my actions or my attitudes prove to be contrary to the rules. I give Solus Christus permission to use any pictures of me in publications for their ministry.

Home
Who We Are
How We Help
How You Can Help
Contact Us

P.O. Box 416
East Bend, NC 27018
Call us 336-813-3007