Project Hope Mens Admissions
Fill out the form carefully for registration
Who is Filling out this Form
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First Name
Last Name
Student Name
First Name
Middle Name
Last Name
Birth Date
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Year
Gender
Please Select
Male
Female
N/A
Social Security Number
*
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What hometown are you originally from?
Mobile Number
Format: (000) 000-0000.
Phone Number
Format: (000) 000-0000.
Work Number
Format: (000) 000-0000.
Which location are you interested in ?
Please Select
Florida
Texas
Arkansas
How did you hear about us?
Do you have
Drivers License
State ID
No ID
What is your sexual orientation ?
Straight
Gay
Bisexual
Are you..
Single
Married
Divorced
Separated
How many children do you have?
Can you Read and write?
Yes
No
You are required to Shave every morning and not have hair that goes below your neckline and/or any type of dreads. Are you ok with this? If you show up with dreads or long hair you will be made to cut it or you will not be accepted.
Yes I agree to the hair policy
No i do not agree (If no End Interview here)
Legal Questions
Do you have any pending court dates?
Please Select
Yes
No
Unsure
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 have any open warrants?
Please Select
Yes
No
Unsure
If so, where and for what crimes?
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
How Many Times a Day do you take meds
Please Select
1
2
3
4
Have you been ever diagnosed with any of the following
Depression
Anxiety
PTSD
Bipolar
Schizophernia / Hearing Voices
Eating Disorder
Cutting or Self Harm
None
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
We do not accept anyone who receives any MENTAL HEALTH payments Are you currently receiving any of the following
Unemployment
Social Security
Disability
Other
If yes then what and how much (If accepted this will be further discussed as far as payments and induction fee)
Project Hope/Saving Grace requests a one-time, non-refundable induction fee of $1,000.00. Please indicate if/ how your payment(s) will be made below:
Full 1000
2 x $500
3 x $333
Payment Plan
Unable to Afford
**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?
Yes
No
**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?
Yes
No
**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?
Yes
No
**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.
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
Please Type Clients Email Use This Example. If the email is John@Gmail.com please type it in the box as John AT Gmail DOT COM. If THEY do not have an email then please get an email of one of their family members THIS IS NEEDED
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