APPLICATION: STILLWATERS OUTREACH CENTER

Transcription

1 General Information: APPLICATION: STILLWATERS OUTREACH CENTER You must be sick of your lifestyle and desire a complete and total change, which WILL be accomplished through the LORD JESUS CHRIST! We are not a drug/alcohol rehabilitation facility. We are a Christian Discipleship Program, designed to teach you and train you to be a disciple of the Lord Jesus Christ, thereby freeing you from drugs, alcohol, depression, promiscuity, etc. Name (First, Middle, Last): Date of Birth: / / Current Address: Social Security Number: - - Driver s License Number: State: Valid Driver s License: Yes No Expiration Date: / / If Driver s License is NOT valid, then please explain: Marital Status: Name of Spouse: How many times have you been married? Family/Emergency Contact Information: Please provide the name, address, and phone number or your nearest family member(s) if applicable. Name (First, Middle, Last): Street Address: City: State: Zip: Phone Numbers: (home) (cell) Name (First, Middle, Last): Street Address: City: State: Zip: Phone Numbers: (home) (cell)

2 Children: Name Sex (M/F) Age Where are they living? Who has custody? Visitation: List any family or friends to be considered for visitation: (We reserve the right to review and approve those listed for visitation. We may deny request) Medical History: (physican statement may be required) Are you currently taking any prescription medications? (yes or no) If YES, please list the name and dosage of the medication and the reason for taking it below: (Understand we may deny use of the following and accept no responsibility for doing so. It is you own decision to accept our terms and agree to NOT continue using those noted below by manager or Board, If you do not agree or feel you health would be in danger, you may need to consider another facility. ) Medication Name Dosage Reason for taking meds Staff Comment ` Have you had any hospitalizations or surgeries in the past year? If so, please explain. Have you ever attempted suicide? Have you ever self-mutilated?

3 Do you have any health conditions that could prevent you from completing this program? If yes, please explain: Have you been diagnosed with any other medical conditions? If so, please list: Do you currently have health insurance? Name: # Phone# Get a copy of insurance card. Legal History: Have you ever been arrested? (Y/N) If yes, list arrest dates, charges and county of arrest. (use reverse side if necessary) Are you currently on probation or parole? (Y/N) Probation/Parole Officer contact information: Name: Phone Number: Address: County: Have you been court ordered to complete a program? If yes, give details. Do you have any outstanding warrants? Are you currently in drug court? Do you currently have any outstanding court fees, probation fines, etc? Amount owed: Due Date: Is there any agency that needs to be notified of your participation in this program? If so, please explain:

4 Education: What was your highest level of education completed? Did you attend college/technical school or graduate from a college program? If so, please list the college and your major: Please list your employment history for the past 5 years or last 3 jobs: What are your skills and abilities in the work force? Spiritual: Are you a Christian? Yes No Not Sure Have you attended church activities in the last 12 months? Where? Were you ever active in regular church activities? Where/What? Have you participated in another faith based recovery program before? If yes, where? Have you ever been a resident of another recovery program (non-christian teaching) before? If yes, where? If accepted, are you willing to abide and participate in Christian teaching and programs? Why do you want to enter the Still Waters program? Do you understand you will be required to participate in the study of the Holy Bible? Do you understand Christian teaching will be the base of this program? Do you agree to abide by all rules and regulations set by Still Waters?

5 (Initial) If you abandon the program, you have one week to pick up your belongings. Unless other arrangements have been made, at such time, any personal effects become property of Still Waters. (Initial) Leaving the property, for any reason, without expressed permission from the staff, will result in immediate dismissal. Re-entry will mean re-applying for entry consideration. (Initial) Still Waters is not responsible for any injuries incurred, on or off property, while you are a resident in the program. (Initial) Upon entry into the program, you will be administered a drug/alcohol screen. This is the only test that you may test positive for any drugs or alcohol. While a resident at Still Waters, random drug/alcohol screens will be administered at the cost of the resident. Any positive drug/alcohol screens, will result in removal from the program. Still Waters' drug/alcohol screen is the sole determining test for eligibility in Still Waters. (Initial) The program at Still Waters is based on teaching from the Holy Bible. A 12 step program with step references will also be integrated in the required program. I understand, if accepted in the program, to be openminded to Bible study, as well as, Christian programs and Christian outreach services. (Initial) Still Waters requires a $300 entry fee and the first month residential fee of $500 upon entry. The monthly residential fee ($500) will be required for the remainder of the stay. IF the resident begins working, a portion of her wages will be applied to residential fees. Remaining balance of fees must be paid by the person cosigning this form or by scholarship IF available. I,, agree and understand the residency fee of $600 monthly set forth by Still Waters. Payment is due prior to the first of each month. A late fee of $20 will be charged after the 5th of the month if not paid. A result of non-payment of these fees can result in the resident's dismissal from the program. Upon entry, a minimum of one month's payment will be required. If midmonth entry should occur, the balance for that month will be applied to the end of the program period. ALL PAYMENTS MADE ARE NON REFUNDABLE! CHECKS OR MONEY ORDERS SHOULD BE MAILED TO THE BELOW ADDRESS. NO CASH BY MAIL PLEASE! (Special residential fee requirements: Applicant Date Responsible Party/ Person Providing Financial Support Date Staff Member Date Still Waters requires a $300 entry fee and the first month residential fee of $500 upon entry. The monthly residential fee ($500) will be required for the remainder of the stay. IF the resident begins working, a portion of her wages will be applied to residential fees. Remaining balance of fees must be paid by the person co-signing this form or from scholarship IF available. Still Waters, 2699 Hwy 221 North, Douglas, GA (912) stillwaters221@gmail.com