Apply

Apply to the Carpenters Arms

The Christian drug and alcohol rehabilitation centre for men.

Please complete all the form fields below as accurately as possible.

Step 1 of 8

Personal Details
What gender are you?*
- Male
- Female
Are you pregnant or do you think you might be?
- Yes
- No
Name*
First Last
Date of Birth*
Age*
Home Address
Street Address Address Line 2 City County Postcode Country
Telephone (Landline)
Mobile*
Email
Ethnic Status*
Religion*

NB: You do not have to be a Christian to be a resident at The Carpenter's Arms.
We request that all residents respect the Christian aspect of the programme. Would you be willing to do this?*
- Yes
- No

Benefits & Contacts
What Benefit do you receive (if any)?*
- Employment Support Allowance ESA
- Job Seekers Allowance JSA
- Disability Living Allowance DLA
- Universal credit
- Personal Independence Provision PIP
- Other, please specify
- None
Other Benefits

In the event of funding not being made available to cover the costs of your stay at the Carpenter's Arms, we shall require you to pass these allowances onto the Charity. The normal rate for residential care at the Carpenter's Arms can be found in our costs leaflet.
Next of Kin
First Last
What relation are they to you?*
Next of Kin Address
Street Address Address Line 2 City County Postcode Country
Their telephone Number
Who referred you?*
First Last
Referrer's profession
Referrer's Address
Street Address Address Line 2 City County Postcode Country
Referrer's Telephone
Referrer's Email

Social & Addiction Workers
If you have a Social Worker please let us have his/her name and contact details:
Social Worker's Name
Social Worker's Address
Street Address Address Line 2 City County Postcode Country
Social Worker's Telephone
Social Worker's Email
What is your Local Authority or Drug Action Team (DAT)?
Your Drugs/Alcohol Worker
If you have a Drugs/Alcohol Worker please let us have his/her name and contact details:
Drugs/Alcohol Worker's Name
First Last
Drugs/Alcohol Worker's Address
Street Address Address Line 2 City County Postcode Country
Drugs/Alcohol Worker's Telephone
Drugs/Alcohol Worker's Email

Drug Use
In this question include alcohol or solvents if they are among the substances you use:
What is the main drug that you use?*
What is the 2nd drug that you use?
What is the 3rd drug that you use?
What other drugs do you use?
Please say why you want to give up drugs/solvents/alcohol and come to The Carpenter's Arms:*
If you have applied to any other Rehabs, please list their names and addresses below:
Do you understand that you will not be able to take any addictive drugs whilst you are a resident at The Carpenter's Arms?*
- Yes
- No
Do you understand that you will not be able to drink alcohol at any time whilst you are a resident at The Carpenter's Arms?*
- Yes
- No
Do you understand that you will not be able to smoke whilst you are on the program at The Carpenter's Arms?*
- Yes
- No
Certain mood altering medication prescribed by a doctor may not be permitted. Please let us know if you are taking any such medication:*
Detoxification*
You can apply to do a chemically-based medically supervised reduction & detox if you are already on a script. If this is not appropriate for you a “Cold Turkey” approach may be suitable. Once we have done your telephone interview we will submit it to a Substance Abuse Specialist GP for his advice. Do you think that you would be able to go through this at The Carpenter’s Arms.
- Yes
- No

Health Issues
What medication are you taking at present, if any?*
Please tell us about any hospital admissions you have had, what they were for and when:*
Have you ever self-harmed in any way?*
- Yes
- No
If so, when was that?
Have you ever attempted suicide?*
- Yes
- No
If so, when was that?
What is your Primary Care Trust?
If you have a Doctor please let us have his/her name and contact details:
If you have a Doctor please let us have his/her name and contact details:
Doctor's Name
First Last
Doctor's Address
Street Address Address Line 2 City County Postcode Country
Doctor's Telephone
Doctor's Email
If you have a Psychiatrist please let us have his/her name and contact details:
If you have a Psychiatrist please let us have his/her name and contact details:
Psychiatrist's Name
First Last
Psychiatrist's Address
Street Address Address Line 2 City County Postcode Country
Psychiatrist's Telephone
Psychiatrist's Email

Legal Issues
Please state your current legal status (if applicable):
Any Outstanding charges?*
- Yes
- No
Date of your next Court appearance:
Details of your Current Sentence:
Parole/HTC/Release date(s):
Are you on Police Bail/Court Bail?*
- Yes
- No
If Yes, then what charges?
Prison No. and Address (if applicable)
Please list your Previous Convictions:
Have you ever been convicted of any Schedule 1 offences? (of a sexual nature or to do with offences with minors)
- Yes
- No
Have you ever been convicted of Arson?
- Yes
- No
Probation Officer
If you have ever had a Probation Officer please let us have his/her name and contact details:
Probation Officer's Name
First Last
Probation Officer's Address
Street Address Address Line 2 City County Postcode Country
Probation Officer's Telephone
Probation Officer's Email
Solicitor
If you have a Solicitor please let us have his/her name and contact details:
Solicitor's Name
First Last
Solicitor's Address
Street Address Address Line 2 City County Postcode Country
Solicitor's Telephone
Solicitor's Email

Signature and Authorisation*
The answers that I have given throughout this application form are true and accurate and I now apply to come to The Carpenter's Arms. I have read the information pack and if I am offered a place at The Carpenter's Arms I am prepared to co-operate fully with the programme and abide by the Conditions of Residence detailed in the information pack. I authorise the staff of The Carpenter's Arms to seek general, medical, social, psychiatric, pre-sentence and legal reports about me for the purpose of considering my application to join their rehabilitation programme, on the understanding that it will be treated in the strictest confidence.
- I Agree
Data Protection*
By using this form you agree with the storage and handling of your data by this website.
- Please tick the privacy checkbox.
Email
This field is for validation purposes and should be left unchanged.

Get in touch with the Carpenters Arms

For help, to learn more about our work or any thing else please get in touch today!

Why choose the Carpenter's Arms?

Our staff team are completely committed to our programme participants

Success Stories

Find out how joining the Carpenters Arms programme has had a massive effect on the lives of those who have joined in and their friends and family too.

Our Awards

We are honoured to have received some awards for our work.

FIND OUT MORE

How to Apply

If you are interested in applying to become a resident at the Carpenter’s Arms, or know someone who is please read our how to apply page for more information.

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The Carpenters Arms

Apply to the Carpenters Arms

Step 1 of 8

Personal Details

Benefits & Contacts

Social & Addiction Workers

Your Drugs/Alcohol Worker

Drug Use

Health Issues

If you have a Doctor please let us have his/her name and contact details:

If you have a Psychiatrist please let us have his/her name and contact details:

Disability Monitoring

Legal Issues

Probation Officer

Solicitor