New Beginnings Ministry Application for Admittance 1258 Greater Hope Road, Martin, GA 30557

Transcription

1 New Beginnings Ministry Application for Admittance 1258 Greater Hope Road, Martin, GA Print this form and fax it to or mail it to address shown. For additional questions call Your Commitment The first 60 days of your stay at New Beginnings is filled with many challenges. This most often includes homesickness, struggles with trust, environmental changes, and a roller coaster of emotions. The first inclination of the resident is the desire to leave prematurely before the adjustment period is complete. We have found that after the first 60 days, most of this insecurity passes. Unfortunately, ladies walk away from their opportunity with New Beginnings because they do not give themselves enough time to make the necessary adjustments. With this in mind, we are requiring a strong commitment on your part to enter this ministry with a determination in your heart to see it through to the end. Your signature to this commitment form is your agreement not to compromise your decision to change, and, therefore, agree to give no time or expression to ideas such as: I m too homesick, This is too hard, I m not ready for this or I don t want God shoved down my throat. We understand that feelings of homesickness and missing your family is valid; however, you must determine that you will not allow these feelings to drive you from your commitment to what God has for you through New Beginnings. Your signature represents your commitment and desire to do what it takes to achieve freedom and healing. We are committed to you as long as you are committed to Jesus and His change in your life. IF YOU DO NOT AGREE TO THIS COMMITMENT, PLEASE DO NOT PROCEED WITH THE APPLICATION PROCESS. If you do agree, please sign and proceed with the Application. Signature of Applicant Staff Witness 1-Rev. 1/24/13

2 WE ARE A SMOKE FREE FACILITY There is a non-refundable $25.00 fee to process your application. All checks and money orders are to be made out to: New Beginnings Ministry. Applications will be processed once this fee is received. Be sure to include your contact number for a phone interview. The information contained in this application will be considered confidential information and will not be released except on a need to know basis. If any of this information is falsified, it will be reason for immediate dismissal from the program. By completing this application, the applicant does not commit in any way that she will become a client at New Beginnings, Inc. This application is strictly for screening purposes and further steps must be taken before an applicant is accepted into the program. FOR STAFF USE ONLY Application Received in Office: of Interview: Status: Admittance : New Beginnings Ministry Application for Admittance 1258 Greater Hope Road, Martin, GA Print this form and fax it to or mail it to address shown. For additional questions call Voluntary Court Mandated How Long? Completion : Reason for Non-Acceptance: GENERAL INFORMATION Today s : First Name: Middle Name: Last Name: Maiden Name: Other names used: Phone Number for Interview: DOB: Age: SS: Current residence: Own Home Parents Relative Friend Detox Incarcerated Homeless Address line 1: Address line 2: City: State: Zip: County: County you entered program from: Referred by: Name of Contact person if at a facility: Phone number for Interview: In case of emergency notify: Relationship to you: Phone Number: FAMILY INFORMATION Marital status: Single Married Separated Divorced Widowed Name of spouse: Phone Number If widowed, for how long? How did death occur? Children: Names/Ages: Where are they now? Do you have visitation rights? How often? 2-Rev. 1/24/13

3 Is DFCS involved? Case worker s name What was your last job and how long did you work there? What types of employment have you held in the past? County/State: HEALTH INFORMATION Rate your health: Very good Good Average Declining Height: Weight: Recent weight changes: Are there any medical (mental or physical) conditions that you have been diagnosed with? Please explain in detail: of last medical exam: Diagnosis: Have you been tested for HIV? Have you been tested for HepA? Have you been tested for HepB? Have you been tested for HepC? Have you been tested for TB? Have you been tested for STDs? Have you had a recent Pap? Have you been tested for a mental illness? What was your diagnosis? Do you accept this diagnosis as true? Explain: If yes, when? What is the name/number of the doctor who diagnosed you? What medications are you currently on? How long have you been on each and why? Are you currently under a doctor s care at this time for mental health reasons? Doctor s name: Phone #: When was your last dental check up? List any dental problems that you have: Do you have any communicable diseases at the present time? If yes, please list: If yes, what kind of treatment are you receiving? Are you receiving any benefits or assistance from the government for a disability? Amount: $ 3-Rev. 1/24/13

4 Kind of assistance: Disability SSI Food Stamps Medicaid Medicare Personal Insurance Personal Insurance Co. If for Disability, what is the disability: How many hours a week are you allowed to work? Do you honestly believe that you are disabled and not capable of working? We are not a medical facility and we only make intermittent or emergency trips to the doctor. You need to inform us of ALL medical conditions at time of interview and on the application. Omission or misleading information is grounds for dismissal. I, agree to the above conditions. Signature LEGAL INFORMATION Are you currently incarcerated? If yes, where? County: What is the crime that led to your incarceration? Do you have a tentative release date? When is it? Max out date: Counselor s name: Do you have an address to parole out to? Do you have cases pending? If yes, when is your court date? What are the charges? Are you on parole/probation? For how long? Name of parole/probation officer: Explain the circumstances of any legal trouble: County/State: Do you have a Public Defender? Attorney? Name: Address, if known (or county, city, state): If not presently, have you ever been incarcerated? When and where? What was the crime that led to that incarceration? 4-Rev. 1/24/13

5 PERSONAL INFORMATION Age that you began using drugs: Age Addicted: Are you presently addicted? What was your drug of choice? List any narcotics that you have used outside of medical reasons: Have you ever used a needle? For what drugs? Have you ever been detoxed? : Have you ever been hospitalized because of drugs? Where? Explain: Have you ever been in rehabilitation before? How many? Name of Program(s): Was it: Faith-based? Secular? In-house? How long? Did you complete it? How long in the program before you are allowed to work or miss the classes being taught? Did you attend A.A. or N.A. meetings before or after attending an in-house program? How many times have you been in jail/prison before seeking help? Longest time clean since you started using drugs? How did you do it? _ For how long have you used? EDUCATION When did you last use? What is your level of education? Elementry School Middle-School High School Some college College Graduate Technical College Trade School Other Do you have a high school diploma? Where did you attain it? What grade did you complete? Do you have a G.E.D.? Where did you attain it? Are there any other areas of weakness in your life other than drugs/alcohol for which you feel that you need assistance? Explain: SPIRITUAL INFORMATION Do you believe in God? Do you believe that the Bible is the inspired Word of God written by God using men? Have you, at any point in your life, been involved in any Church? What church? What denomination(s)? Are you willing to make a life-long commitment? Do you believe that you are born again? 5-Rev. 1/24/13

6 How long have you been born again? What are your goals at this point in your life? Are you willing to do and give up whatever it takes? What does serving God mean to you? What do you expect to get out of your stay at New Beginnings? Exactly why do you feel that now is the time for you to allow God to turn your life around? Please explain in detail: Why have you chosen New Beginnings as a possible rehab? How did you hear about New Beginnings? FINANCIAL INFORMATION Will your personal financial needs be sponsored by your family, church ministry, or individual while at New Beginnings? Who exactly? Person to Contact: Address: Phone Number: New Beginnings provides food and shelter, but we will not be responsible for medical expenses or prescriptions. It is the responsibility of the family or your sponsoring agency to cover these expenses. Arrangements should be made prior to acceptance. If none of the above is available to you, please inform the director of New Beginnings during your initial interview. This form needs to be printed, filled out and faxed to: If you have no fax, please mail the completed form to: New Beginnings Ministry 1258 Greater Hope Road Martin, GA If you have any questions, please call: Rev. 1/24/13

7 Fee Statement Rent per month $ $1500 per month (sliding scale) Medicals (labs, Rx, Dr. appt.) first month Spending money (depending on personal requirements) per month Application Fee first month Transportation Fees Due to rising gas prices, we find it necessary to charge the following for Transportation: Trips to Drs. (except for an emergency), Attorneys, and missed ride to work Toccoa, Lavonia Hart, Royston, Habersham Athens, Gainesville, Commerce Transportation to DFACS, Probation, or Public Defender will not be charged. I have read and agree to the fees as stated above. Signature Staff Witness 7-Rev. 1/24/13