The Empowerment Resurrection Center of New Jersey, located in Bridgeton, New Jersey, is a drug and alcohol addiction assistance and rehabilitation organization, accepting clients from the New Jersey, Pennsylvania and Delaware tri-state area and beyond.

Formally Faith Farm Recovery Addiction Center
 

ERC-NJ provides the only adult, long-term residential drug and alcohol program
in the  New Jersey, Pennsylvania and Delaware tri-state area.


 

 

21 Stretch Road

Bridgeton, NJ 08302-9295

       

Office: 856.575.0500 
Fax: 856.575.0505  

   

marchase5111@aol.com

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Pre-admission Application Form

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use capital letters only where appropriate.

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Applicants FULL Name

       Ex. First, Middle, Last

 

Applicants Address 
 

 

Applicants City                             State                       Zip 
       

 

Applicants County

 

Applicants Home Phone 

 

Applicants Cell Phone 

 

Applicants Work Phone
 

 

Applicants Email
 

 

Applicants Date of birth (must be 18 years old)
  
   
   Ex. July 10, 1981

 

Level of Education ( Check ALL that apply.)
   No GED or High School  GED  High School Diploma  Vo-tech College Degree

 

Are you currently employed?
     Yes      No

 

Marital status 
     Single    Married    Separated     Divorced

 

Current Legal Problem(s), if any 

 
 
    Briefly Describe - If more space is needed continue typing.

 

Do you have Health Insurance?
  Yes   No

 

If YES, Name of Health Care  Provider 

 

 

How were or who you referred to our program? 

 

 

First Drug of Choice                      Route of Administration

    

 

Second Drug of Choice                  Route of Administration

    

 

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Emergency Contacts FULL Name 

 

Emergency Contact Address
 

 

Emergency Contact City              State                      Zip
       

 

Emergency Contact Phone
 


Emergency Contact Cell Phone


Emergency Contact E-mail

 

Other Information

 
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501 non-profit organization

So then faith cometh by hearing,
& hearing by the word of God.
                                    - Romans 10:17