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Resident Application

Important Notes:

  • In order to focus on healing, residents are not employed outside the home during their program stay at Legacy, nor will they have possession of personal mobile devices

  • The application fee will be applied to the entrance fee upon acceptance

  • The application fee will be refunded if the application is declined

Please answer thoughtfully and thoroughly. 

Applications with incomplete answers will not be considered.


Today's Date
Month
Day
Year

I. PERSONAL

Birthday
Month
Day
Year
Can you read and write?
How did you hear about Legacy?

Emergency Contact

Did you complete high school?
Did you or do you attend college or trade school?

II. MARRIAGE & RELATIONSHIPS

Complete this section if you have children and/or have ever been married. Otherwise, proceed to section III.

Do you have any previous marriages?
Yes
No
Do you have children?
Yes
No

III. MEDICAL

Do you have any medical conditions or health issues that require regular visits to your doctor?
Yes
No
Do you have a Naltrexone implant?
Yes
No
Are you currently using alcohol and/or drugs?
Yes
No
Are you currently taking any prescription medications?
Yes
No
Do you anticipate needing this medication while you are in the program?
Yes
No
Have you ever used prescription drugs for non-medical purposes?
Yes
No

**Legacy women must have a negative drug test prior to admission**

Have you ever been diagnosed by a mental health professional?
Yes
No
Have you ever been hospitalized for behavioral or emotional problems?
Yes
No
Have you ever attempted suicide?
Yes
No
Check all health issues you currently have or had in the past.
Do you have any allergies? (food, seasonal, animal, etc?)
Yes
No
Do you have any dietary restrictions?
Yes
No
Do you have any existing dental problems?
Yes
No
Are you aware that Legacy has a routine physical work component?
Yes
No
Do you have a physical limitation that would require accommodation for performing physical work? (Ex. bad back?)
Yes
No

Legacy is not a medical facility. If your health requires you to see a doctor on a regular basis this program may not be for you. We have no medical staff on site and are limited to basic first-aid. In case of an emergency we will take you to a local hospital. In the case of acute illness, we will take you to a local clinic to see a healthcare professional. If doctor appointments become required on a frequent basis, you may be subject to a medical discharge from the program. 

Do you understand that Legacy is not a medical facility?
Yes
No

IV. LEGAL

We will perform a background check prior to admission. Criminal history does not necessarily disqualify you from the program.

Have you ever been arrested or in jail?
Yes
No
Are you on Supervision, Parole, or Probation?
Yes
No

Do you have any pending:

Are you court-ordered to enter a recovery program?
Yes
No
Do you have a valid driver’s license?
Yes
No
If no, do you have a state ID?
Yes
No
Are you a U.S. citizen?
Yes
No
Are you currently receiving any kind of government assistance?
Yes
No
If yes, check all that apply:

V. SPIRITUAL


VI. IN SUMMARY


The above information is true to the best of my knowledge. 


P.O. BOX 708

GROTON, CT 06340

860.245.8949

EXECUTIVE.DIRECTOR@LEGACYFORWOMEN.ORG

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"Legacy: A Residential Recovery Program for Women, Inc. (Fed Id-85-2098463) is a non-profit organization recognized as tax-exempt under Internal Revenue Code section 501(c)(3)"

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