Saving Grace Women's Admissions
Fill out the form carefully for registration
Who is Filling out this Form
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First Name
Last Name
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How did you hear about Saving Grace
Student Name
First Name
Middle Name
Last Name
Birth Date
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Year
Gender
Please Select
Male
Female
N/A
Height and Weight
Social Security Number
*
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What hometown are you originally from?
E-mail
example@example.com
Mobile Number
Phone Number
Work Number
Which location are you interested in ?
Please Select
Florida
Texas
Mississippi
Tennessee
Arkansas
Do you have
Drivers license
State ID
None
Other
What is your sexual orientation ?
Straight
Gay
Bisexual
Are you..
Single
Married
Divorced
Separated
Widowed
Dating Someone
Common Law Marriage
Could you be pregnant at this time ?
Yes
No
Im not sure
How many children do you have?
Can you Read and write?
Yes
No
Legal Questions
Do you have any pending court dates?
Please Select
Yes
No
Unsure
If so Please give information
Are you currently on probation or parole?
Probation officer name Location Phone number Email
Have you ever been convicted of a sex crime
Please Select
Yes
No
Not Sure
Drug / Alcohol History
What are you currently using and or struggling with?
When was the last time you used?
How long have you been consecutively using for?
Are you in need of a detox first
Please Select
Yes
No
Are you currently using any nicotine products
Please Select
Yes
No
Medical / Mental History
Do you have medical insurance?
Please Select
Yes
No
If yes what is it
Do you have any of these medical conditions
Hepatitis
HIV / AIDS
STD's
TB
Asthma
High Blood Pressure
Diabetes
Epilipsy / Seizures
Other
Please explain if any
Any other medical conditions not listed that we need to be made aware of that may hinder you from working while in the program
Any Allergies
Food
Medecine
Other
If so what
Mental Health MHMR
Have you been ever diagnosed with any of the following
Depression
Anxiety
PTSD
Bipolar
Schizophernia / Hearing Voices
Eating Disorder
Cutting or Self Harm
Other
Have you ever been suicidal
Please Select
Yes
No
If so please explain the circumstance
Please list any an all meds that you are taking. These include prescription and over the counter meds
You are required to have a 90 day supply of meds upon admission. Are you able to obtain these before your entry date
Yes
No
Not Sure
Are you currently receiving any of the following (Please note If you are receiving any MENTAL HEALTH payments or checks we are unable to accept you at this time)
Unemployment
Social Security
Other
If yes then what and how much (This will need to be further addressed with your intake counselor on your final interview before being accepted)
We ask for a one-time non-refundable $1000 induction fee. Will you or your family be able to make a full payment? or make several payments
Full 1000
2 x $500
3 x $333
Payment Plan
Can not afford at this time
Name of someone that can donate
Disclosure We are NOT a Medical Facility If you are due for a doctors checkup or are in need of dental work, we strongly advise that you take care of that before you entering our program. YOU WILL NOT see a doctor for at least 90 days unless it is an emergency. The only meds that you are allowed to bring are the meds we have talked about in this interview. If you claim to need a medication that you did not mention in your interview you will not be allowed to get that medication. Expect Discomfort once your body is clean and sober you will feel pain that your DOC was numbing. After going over this interview are there any further questions that you have for me at this time? The interview is now completed If you are interested in coming to our program i will email you to Read the Rules of the Program and sign them before arriving. Do you understand everything that we have talked about today and what is involved.
Yes
No
The interview is now completed If you are interested in coming to our program i will need you to Read the Rules of the Program and sign them before arriving. Please Provide a Email address or Cell Phone Number Where they can be sent to you.
Personal Notes Post Interview
Submit Application
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