Home
About
Canaan's House
Intake

Welcome to Project Exodus

A Christ-centered home for reform. Let's get started with applying for Canaan's House.

Intake Form

Full Name

Phone *

Email *

Gender:

Male
Female
Non-binary
Prefer not to say
No elements found. Consider changing the search query.
List is empty.

Address

Street Address

City

State

Driver License Number

DL#

Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo, The Democratic Republic of the
Cook Islands
Costa Rica
Cote D"Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See (Vatican City State)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran, Islamic Republic Of
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea People's Democratic Republic
Republic of Korea
Kuwait
Kyrgyzstan
Land Islands
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libyan Arab Jamahiriya
Liechtenstein
Lithuania
Luxembourg
Macao
North Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Federated States of Micronesia
Moldova, Republic of
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestinian Territory, Occupied
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russian Federation
Rwanda
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Eswatini
Sweden
Switzerland
Syrian Arab Republic
Taiwan
Tajikistan
Tanzania, United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
UK
Ukraine
United Arab Emirates
United States
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
No elements found. Consider changing the search query.
List is empty.

Postal code

YOUR FAITH

How did you hear about us

Do you attend a church?

Enter Here

Yes
No
No elements found. Consider changing the search query.
List is empty.

What is the church name?

Denomination preference?

ABOUT YOUR JOURNEY

Are you currently in recovery?

Enter Here

Yes
No
No elements found. Consider changing the search query.
List is empty.

Sobriety Date

Which drugs/alcohol have you used in the past and with what frequency?

Are you currently on Medical Assisted Treatment (such as suboxone or methadone)?

Enter Here

Yes
No
No elements found. Consider changing the search query.
List is empty.

Are you currently in treatment or incarcerated?

Enter Here

Yes
No
No elements found. Consider changing the search query.
List is empty.

If so, Where?

Counselor's Name:

Counselor's Email:

Counselor's Phone Number:

TRANSIONAL HISTORY

Have you ever lived in transitional living before??

Enter Here

Yes
No
No elements found. Consider changing the search query.
List is empty.

If yes, please specify:

Did you complete the program?

Enter Here

Yes
No
No elements found. Consider changing the search query.
List is empty.

If no, please specify reason for leaving:

Have you ever participated in Christ-centered Recovery? (Celebrate Recovery)

Enter Here

Yes
No
No elements found. Consider changing the search query.
List is empty.

Are you willing to participate in Christ-centered recovery?

Enter Here

Yes
No
No elements found. Consider changing the search query.
List is empty.

Do you have a relationship with Jesus Christ?

Enter Here

Yes
No
No elements found. Consider changing the search query.
List is empty.

Please explain the importance of prayer and bible study in your life:

Please write your personal testimony/life story and include why you think that Canaan's House can help you succeed in your recovery journey.(We want to know about you - please include at least 2-3 paragraphs.) Membership applicants will be voted in by existing members of the house. The information you write on this page will be read at a Project Exodus meeting.

By checking this box, I understand that any recovery services offered at Canann's House Sober Living Home are exclusively Christ-centered in nature and are not subject to licensure or regulation by the Texas Commission on Alcohol and Drug Abuse. This program offers only non-medical treatment and recovery methods such as prayer, Christian 12-step study, moral guidance, spiritual counseling and scriptural study.

Please complete the form to begin the intake process. All information is kept confidential. Fields marked with an asterisk are required. For assistance, call our team at (409) 555-1234.

Project Exodus Sober Living

A Christ-centered home for men and women rebuilding their lives in recovery.

Email: [email protected]

Start Intake

For churches & families

Want to refer someone or explore a partnership? Reach out and our team will connect with you.

Contact Team