Walls of Salvation

Seeds of Salvation, LLC -- Sober Living Home Application (Las Cruces, New Mexico)

Applicant Information

Full Name (Required)

Date of Birth (Required)

Phone Number (Required)

Email Address (Required)

Current Address (Required)

Please note that this area is limited to 300 characters.

Emergency Contact Name (Required)

Relationship (Required)

Emergency Contact Phone (Required)

Background Information

Are you currently on probation or parole?

Yes

If yes, please explain

Please note that this area is limited to 1000 characters.

Have you ever been convicted of a violent offense?

Yes

If yes, please explain

Please note that this area is limited to 1000 characters.

Do you have any pending legal cases?

Yes

If yes, please explain

Please note that this area is limited to 1000 characters.

Substance Use History

Primary substance(s) used (Required)

Please note that this area is limited to 500 characters.

Date of last use (Required)

Have you completed a detox or treatment program?

Yes

If yes, where and when

Please note that this area is limited to 500 characters.

Are you currently enrolled in any recovery program?

Yes

If yes, please explain

Please note that this area is limited to 1000 characters.

Medical & Mental Health

Do you have any medical conditions we should be aware of?

Yes

If yes, please explain

Please note that this area is limited to 1000 characters.

Are you currently taking prescribed medications?

Yes

If yes, list medications

Please note that this area is limited to 1000 characters.

Do you have a diagnosed mental health condition?

Yes

If yes, please explain

Please note that this area is limited to 1000 characters.

Spiritual & Program Commitment

Walls of Salvation is a faith-based program rooted in biblical principles. Are you willing to participate in:

Daily structure and accountability

Yes

Bible studies and spiritual growth activities

Yes

Group meetings and house rules

Yes

Why are you seeking entry into this program? (Required)

Please note that this area is limited to 2000 characters.

Employment & Financial Plan

Are you currently employed?

Yes

If yes, where

Do you have a plan for employment or income? (Required)

Please note that this area is limited to 1000 characters.

Will you be able to contribute to program fees if required?

Yes

Agreement & Signature

I understand that this is a structured sober living environment. I agree to follow all house rules, remain substance-free, and participate fully in the program.

I certify that the information provided is true and complete to the best of my knowledge.

Walls Of Salvation Application

Walls of Salvation

Applicant Information

Emergency Contact

Background Information

Substance Use History

Medical & Mental Health

Spiritual & Program Commitment

Employment & Financial Plan

Agreement & Signature

Contact Information