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Any false, incomplete, or misleading information provided in this application will result in automatic denial.

Birthday
Month
Day
Year
GENDER
Male
Female
Other

EMERGENCY CONTACT

CURRENT STATUS
Married
Divorce
Single
In a relationship

INFORMATION OF THE PERSON YOU CURRENTLY HAVE A RELATIONSHIP WITH

Do you have any children?
Yes
No

FACILITY CONTACT INFORMATION

Do you know anyone at our facility?
Yes
No
Do you have any current criminal charges
Yes
No
Are you currently on probation?
Yes
No

PROBATION OFFICER INFORMATION

Are you on parole?
Yes
No

PAROLE OFFICER INFORMATION

ATTORNEY INFORMATION

Do you have an open DCS, CPS, DCFS or any other Child Service?
Yes
No
Do you have any prior or present criminal charges involving minors?
Yes
No
Have you been to prison?
Yes
No
Are you required to register as a sex offender?
Yes
No

Any false, incomplete, or misleading information provided in this application will result in automatic denial.

LightHouse Recovery Center

2114 Oak Grove Rd.

Washington, Indiana 47501    

Operating Hours:

Monday - Friday 9am to 5pm

Saturday - Sunday CLOSED 

All locations: +1 812-642-5100.

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lrc.inc.washington@gmail.com

​

© 2023 by Lighthouse Recovery Center, Inc

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