Let's Transform Together

Admissions

Admission Form

Our Vision is to disciple, train and equip our residents through recovery from addiction with the proper Godly skills so they can bring the message of Hope to the community and throughout the region.

Clients Name *

First

Last

Date of Birth *

Address that's on their ID *

Address Line 1

Address Line 2

City

State

Zip Code

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Phone *

Emergency Contact *

Drivers License # *

Email *

Emergency Contact Phone *

SS # *

When is the last time in treatment and where? *

Drug and Alcohol History

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Are you currently using? *

What Substance? *

How Frequent? *

Do you smoke cigarettes? *

Medical History

Do you have any medical conditions? If Yes, what are they? *

Are you on Methadone Maintenance? *

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Saboxone? *

What Milligram? *

Are you suicidal? *

Do you have a history of mental illness? If Yes, what for? *

Are you currently on ANY medications? If Yes, Please Describe: *

Recovery History

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Are you in a 12 Step fellowship? If so, where? *

Have you ever been in a Christian Program before? If so, where? *

Are you attending Church? If so, where? *

Upload Supporting Documents ( Max 10 ): ( ID, etc. )

Click or drag files to this area to upload. You can upload up to 10 files.

Signature *

Save and Resume Later

Let's Transform Together

Admissions

Admission Form

Drug and Alcohol History

Medical History

Recovery History

Give to the Mission

Residential housing, discipleship, counseling and life skills with the emphasis on living a Godly life style through Jesus Christ.

Email

Office Address

Mailing Address