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Welcome to Second Chance Recovery Inc.
Application for Addission
 
  1. Fill out application. Be sure to complte application as thorough as possible. Full name and expected move in date are very important!
  2. Fax application to ( 941) 257-8414, Mail to Second Chance Recovery Inc. PO Box 380594 Murdock, Fl. 33938-0594 or email it to contact@secontchancerecovery.net
  3. Executive director will contact client and/or Treatment Center to arrange a phone or personal interview.
  4. Interview
  5. Upon approval, an acceptace letter and/or phone call will be sent to the client and the treatment center.
 
       Welcome to Second Chnce Recovery Homes:
 
   Name__________________________________ Age_____ DOB__________
   Have you ever applied or lived at Second Chnace Recovery Homes? Y___N___
   Current Address_________________________________________________
   City__________________State________________Zip Code_____________
   Home Phone______________________Cell Phone_____________________
   Work Phone_______________Email Address__________________________
   Social Security #___________________Birth Place______________________
   Height_______Weight_______Hair Color______Eye Color______Race______
   Distinguishing Marks ( scars, tattoos, etc.)______________________________
   In Case of emergency Notify________________________________________
   Phone # (____)__________________Relationship______________________
   Marital Status____________________Do You Have Children? Y____N_____
   Parents Name____________________ Address________________________
   Phone # (_____) _________________Cell Phone# (____)________________
   Are you currently on probation? Yes____ No_____ Where?_______________
   Probation officers name____________________ Phone #(___)_____________
   Are you on community control probation? Yes_____ No_______
   What is your current offense? _______________________________________
   If currently residing outsideFL. or have lived in states other than FL., a criminal background Check(s) for those states must be submitted with this application.
  
   Have you ever commited/been chrged with arson?  Yes_____ No_____
   Have you ever been charged with cruelty to animals?  Yes____ No____
   Have you ever been charged/convicted of a violent crime Yes____ No____
   Have you ever been charged/commited with a sexual crime? Yes___No___
   Do you have the funds to cover entrance fee? Yes___ No___
   Do you have legal idetification? Yes___ No___
   Do you currently have a job? Yes___ No___ Full/part time ( circle one)
   Name of company.________________Supervisors name_________________
   Phone# (___)________________How long employed there?______________
   Do you have a valid drivers license? Yes___No___
   If yes what is the Driver's License # and state issued______________________
   Do you own your own vehicle? Yes___No___
   If yes what is the name o your insurance agency?_________________________
   Policy#____________________Expiration date_________________________
   If for some reason, you cannot pay $100.00 a week, who will you call to help?
   Name_______________________Phone# (____)______________________
   Do you receive any ongoing finacial reimbursments for any reason? (such as, SSI,Disability,Medicaid, Trust Fund, etc.)  Yes___No___
    If yes explain. __________________________________________________
 
       Addition information will be required upon approval and placement in one of our homes. We look forward to meeting you and working with you on your road to recovery.

 

For more information about our inpatient or outpatient treatment programs, call us today at 866.825-1171 and let one of our caring admissions counselors help you with any questions or concerns regarding cost, eligibility and insurance.

We know just what you’re going through and count it a privilege to be able to help. All you have to do is pick up the phone and call.

Take the First Step...

Call Us Today at 866.825-1171
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