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      • CAPE CORAL MEN'S CONDOS
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We Can Help: (239) 333-8079 or (239) 200-1910

We Can Help: (239) 333-8079 or (239) 200-1910

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THE SURRENDER HOUSE

CAPE CORAL SOBER LIVING
FORT MYERS SOBER LIVING
CAPE CORAL MEN HALFWAY HOUSE
FORT MYERS MEN HALFWAY

APPLICATION (PRINT AND BRING AT INTAKE)

THE SURRENDER HOUSE 

Recovery Residence *CAPE CORAL*FORT MYERS 

KARI-ANNE SPILLER -PROGRAM DIRECTOR *239-333-8079 

                                                                                                                                     

 APPLICATION FORM 

General Information: (PLEASE PRINT) Name: 

(Last) ___________________________  (First) ___________________________  (MI) _________________ 

 Street: __________________________ City: ____________________ State: ______ Zip: _____

 S. S. #: __________ - ________ - ___________  Drivers License/State ID: _________________________ 

Birth Date:_____/_____/_____  Cell #: ________ - ________ - _________  

In Case of Emergency: Name: ___________________________ Relation: _______________ 

Tel: ______________ 

Name: __________________________ Relation: _______________ Tel: _______________ 

Are you on: Probation: ____ Y, ____N  

Drug Court Involved: ____ Y, ____N   

PO Name: _______________________________________ Phone #: _______ - _______ - _________ 


Lived at Surrender House before? _________  When/Where?_________________________________  


Referred by/coming from: ___________________________ Physical Condition at Entry: ________________________________________________________________________ 

Emotional/Mental Condition at Entry: ________________________________________________________________ 

Requested Level of care: 

Level 2​   (check one) 

Fort Myers Men ($175 per wk ) _____

Cape Coral Men ($175 per wk) _____ 

Cape Coral Women ($175 per wk)_____

 **NON REFUNDABLE administrative fee is equal to 1 weeks rent at each location** 

I’m taking the following: (PLEASE PRINT) Medication(s): _______________, ________________, _______________, _______________, _________________. 

Reason for Medication(s): _________________________________________________________________________  

Drug/Alcohol and Background History: (PLEASE PRINT)  Drug(s) of Choice: _______________, _______________, _______________, _______________, _______________.  Most Recent Drug(s) Used: (including Alcohol) ______________, _______________  Date of last Use? ____________ 

Have you ever been ARRESTED for a sex crime  YES______ NO ______ 

PRINT NAME: ______________________________________________

SIGNATURE: _____________________________________________ DATE: ___________________ 

                      Educating Our Community * Saving Our Families * Proving God and The 12 Steps work 


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