Level 3: Apply Now - K.I.S.S. Foundation, Inc

Level 3 is a two step process:

You first agree to The Rules below: Sign and send.
Then complete the Application below that. Sign and send.

You will receive auto-confirmation of both to the email address that you provide. Upon review, we will reach out to you with further question/instructions to proceed.

Step 1: Rules agreement

Read all of the rules. Add Name, Consent, Date and Send

Must have a minimum 90 consecutive days of sobriety.
Medication-assisted Treatment (MAT) and/or medical marijuana is
not permitted.
Must have full-time employment with verifiable income or a
verifiable income source.
(Medicaid housing grants are not accepted)
Attendance at 12-step meetings is mandatory. Friday meeting, Helping Hands West, is mandatory.
Use of anabolic steroids, smart powders, and kratom is strictly prohibited.
Biological men only!

The undersigned has read and understands all of the rules and agrees to follow as such.

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Your Name*

First Last

Date

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Step 2: Application

Complete form. Add Consent, Date and Send

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Today's Date (Application date)

SPONSOR'S Name*

First Last

Your Name*

First Last

Phone*

Email*

Date of Birth*

Age*

Referred by?*

Sobriety date

Sponsor

First Last

12-Step Home Group

Substance(s) of Choice?*

Date of Last Use?*

Substance(s) Used?*

Detox Information:

Name of Detox Facility

Date Admitted

Date Discharged

Medical / Psychiatric History:

Any Mental Health History:*

Yes

If YES, Please detail diagnosis*

Psychiatric medications currently taking? If none, type NONE*

Current medical / physical problems:

Medications Currently Taking - If none, type NONE:*

Legal:

Arson Conviction?*

Yes

Convicted Sex Offender?*

Yes

Probation Officer Name

City / County

Parole (PRC) Officer

Phone

MUST BE WORKING OR HAVE AN INCOME TO BE CONSIDERED! PROOF OF INCOME SOURCE WILL BE REQUIRED.

Background checks and drug & alcohol testing will be conducted prior to Residency. By submitting this application you agree that you are able to participate in all aspects of the program and understand the program is a spiritual 12-step based program.

Date

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Level 3 is a two step process:

You first agree to The Rules below: Sign and send.

Then complete the Application below that. Sign and send.

Step 1: Rules agreement

Read all of the rules. Add Name, Consent, Date and Send

Step 2: Application

Complete form. Add Consent, Date and Send

Detox Information:

Medical / Psychiatric History:

Legal:

MUST BE WORKING OR HAVE AN INCOME TO BE CONSIDERED! PROOF OF INCOME SOURCE WILL BE REQUIRED.