Residential Admission 2021

Life Stabilization Program

Covenant Community, Inc. (CCI) is an intensive residential program for men experiencing homelessness and recovering from alcohol and/or substance misuse. CCI is licensed by the Georgia Department of Community Health as a Drug Abuse Treatment and Education Program and is approved to provide residential intensive treatment programming for a capacity of 14. CCI is accredited by the Commission on Accreditation of Rehabilitation (CARF) and the Georgia Association of Recovery Residences (GARR). CCI uses a therapeutic community model to assist its residents in overcoming their addictive disorders and to return to productive, self-sufficient functioning in society.

Please complete the online Admission form in its entirety. It will take approximately five minutes to complete.

Completing this screening does not guarantee placement however, it is a prerequisite for our program.

Selected candidates will be contacted for an in-person interview.

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* 1. Are you a professional within a Medical Detox Facility?

Yes

Other (please specify)

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* 2. What is the Applicant's Contact Information?

Name

Address

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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* 3. What is the Applicant's Gender?

Male

Female

Non-binary

Prefer to self-identify

Prefer not to answer

Other (please specify)

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* 4. What is the Applicant's date of birth?

Month/Date/Year

Date

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* 5. Does the Applicant have the following? (Select all that apply.)

A mental health evaluation

A tuberculosis screening

An RPR (Syphilis) test

A recent physical examination

A Negative COVID-19 result

A COVID-19 vaccination

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* 6. What is the Applicant's racial or ethnic identity? (Select all that apply.)

White or Caucasian

Black or African American

Hispanic or Latino

Asian or Asian American

American Indian or Alaska Native

Native Hawaiian or other Pacific Islander

Another race

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* 7. Is the Applicant a US Veteran?

Yes

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* 8. Has the Applicant ever participated in Covenant Community's residential program?

Yes

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* 9. Does the Applicant have a primary substance use disorder (SUD) diagnosis?

Yes

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* 10. What is the Applicant's source of income?

Employment Earnings

SSI/SSD

TANF/SNAP

Unemployment

Other (please specify)

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* 11. Is the Applicant deemed indigent/homeless?

Yes

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* 12. Does the Applicant have a criminal history?

Yes

Unknown

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* 13. Is the Applicant (Select one.)

Ambulatory

Non Ambulatory

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* 14. Upload Documents

Please upload 1. Mental health evaluation 2. A tuberculosis screen 3. An RPR (Syphilis) test 4. A recent physical examination 5. COVID-19 results

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

Choose File

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* 15. Your Contact Information

Name

Telephone

Organization