Application | Manna House TSL

Ready to take the next step in your recovery journey? Manna House is here to support young men who are committed to living sober, learning life skills, and building a strong foundation for the future. Fill out the application below to begin the process.

You will be contacted within 24 hours of submitting your application.

First name

Last name

Birthday

Month

Day

Year

Phone

Permanent Address

Do you have a substance use disorder?

Yes

What substance(s)?

List of drugs you use addictively.

Date of last drink?

Month

Day

Year

Date of last drug use?

Month

Day

Year

List of all prescribed medications currently taking.

When did you attend your first AA or NA meeting?

Month

Day

Year

How many AA/NA meetings do you attend each week?

Are you employed? If so, who is your employer?

What is your current monthly income?

Place(s) of residence during the past two years. (1/2)

Place(s) of residence during the past two years. (2/2)

Name of last educational institution or school attended.

Are you married? If so, name of spouse.

Provide name and contact info for the first reference who can vouch for your commitment to recovery.

Do you have a court mandated treatment(s)?

Yes

Please provide charge and case number.

Are you on probation, parole or have an upcoming court appearance? If so, please describe the circumstances, charges and State where occurred.

Do you have any open court cases, warrants or active restraining orders? Please Explain.

Provide the date of any upcoming court dates that may be applicable.

Do you currently have any physical or mental health issues (including depression, ADHD, anxiety, overdose, suicide attempts, nervous conditions, hospitalizations, etc.)? If so, please describe. MANNA House TSL LLC reserves the right to request a mental or

Are you currently engaged with any mental health service providers?

Yes

Service Provider Name:

Service Provider Phone Number:

Have you ever been admitted for treatment from a suicide attempt? Please explain.

Have you had suicide ideations in the past?

Current suicidal thoughts or self-harm?

What is your Race and Ethnicity?

Are you developmentally disabled?

Are you currently homeless?

Do you identify as LGBTQ2+?

Are you a Military Veteran?

Do you require physical accommodations?

Are you a Registered Sex Offender?

Father’s name, address, phone number and email address.

Mother’s name, address, phone number and email address.

Emergency contact - name, relation, phone number, email.

Back up emergency contact - name, relation, phone number, email.

What are your short-term goals?

What are your long-term goals?

How do you think residing at MANNA House could help you?

Applicant Acknowledgement I understand that if my application is accepted, I will comply with MANNA House TSL LLC Rules and Policies statement which I have been given the opportunity to read. I understand that these Rules and Policies may change from time to time at the discretion of MANNA House TSL LLC. I further understand that my residency with MANNA House TSL LLC is temporary and transitional. I acknowledge that, as a resident at MANNA House TSL LLC, I am a licensee and not a tenant, and that I have no tenancy rights or interests. As such, I agree that I can be discharged from the premises immediately should it be determined by the House Manager or an Executive Director at their sole discretion to be in the best interest of the house and/or other house members. Should I refuse to leave the premises immediately upon discharge, I acknowledge that I will be considered to be a trespasser and that the local police department will be called to escort me off the property. If the house being used for MANNA House TSL LLC is sold or if the lease for the house is terminated, any residency rights are automatically terminated.

Signature

Signature field is empty.