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Saving Grace Women's Admissions

Fill out the form carefully for registration
Who is Filling out this Form

First NameLast Name
This is a fill in the blanks field. Please add appropriate blank fields and text.
How did you hear about Saving Grace
Student Name

First NameMiddle NameLast Name
Birth Date

MonthDayYear
Gender
Height and Weight
Social Security Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What hometown are you originally from?
E-mail
example@example.com
Mobile Number
Format: (000) 000-0000.
Phone Number
Format: (000) 000-0000.
Work Number
Format: (000) 000-0000.
Which location are you interested in ?
Do you have

Other
What is your sexual orientation ?
Are you..
Could you be pregnant at this time ?
How many children do you have?
Can you Read and write?
Legal Questions
Do you have any pending court dates?
If so, where and what is the current status of the case?
Are you currently on probation or parole?
Probation officer name Location Phone number Email
Do you currently have any open warrants?
If so, where and for what crimes?
Have you ever been convicted of a sex crime
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
Are you currently using any nicotine products
Medical / Mental History
Do you have medical insurance?
If yes what is it
Do you have any of these medical conditions

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

Other
If so what
Mental Health MHMR
Have you been ever diagnosed with any of the following

Other
Have you ever been suicidal
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
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)

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
Name of someone that can donate
**Induction Fee Disclosure** If full or partial induction fee payment(s) are made during the duration of the program, the amount paid will be refunded to the paying party upon successful completion of the program. Do you understand the parameter of this disclosure?
**Travel Expense Disclosure** If full or partial induction fee payment(s) are made during the duration of the program, a portion of the induction fee will be allocated for travel expenses if an individual enrolled in the program is dismissed for violating the program’s policies and procedures or chooses to leave against ministerial counsel. Do you understand the parameter of this disclosure?
**Non-payment Disclosure** If full or partial induction fee payment(s) are not made during the duration of the program, Project Hope/Saving Grace is not obligated to and will not provide travel expenses if an individual enrolled in the program is dismissed for violating the program’s policies and procedures or chooses to leave against ministerial counsel. Do you understand the parameter of this disclosure?
**Medical 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.
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
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Saving Grace Women's Admissions

Legal Questions

Drug / Alcohol History

Medical / Mental History

Mental Health MHMR