Gastonia Potters House Client Application
"A Miracle In The Making"
Date
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Month
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Day
Year
Date
Name
First Name
Last Name
Date of Birth
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Month
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Day
Year
Date
Phone Number
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Area Code
Phone Number
Alternative Contact Number
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Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Gender
Please Select
Male
Female
Referred By:
.
Church Affiliation (If applicable)
Church Contact Name/Number (if applicable)
Sponsor Name (if applicable)
Sponsor Contact Number (if applicable)
Requested Entry Date
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Month
-
Day
Year
Date
Ethnicity
Please list your hobbies/interests and any trade/work skills that you have
Check drugs/alcohol you are currently using
Methamphetamine
Cocaine
Stimulants (pills)
Heroin
LSD or Hallucinogens
Marijuana
Pain killers (not as prescribed)
Methadone
Tranquilizer/sleeping pills
Alcohol
Ecstasy
Describe what kind of withdraw symptoms you are having right now
How often are you using the drugs above? Do you have withdrawal symptoms if you stop using the drugs above? Please describe.
Check drugs/alcohol you have used in the past
Methamphetamine
Cocaine
Stimulants (pills)
Heroin
LSD or Hallucinogens
Marijuana
Pain killers (not as prescribed)
Methadone
Tranquilizer/sleeping pills
Alcohol
Ecstasy
Age of first drug/alcohol use
Is there a history of substance abuse/alcoholism in your family? Please describe.
Have you ever had convulsions, seizures of blackouts due to drug use or withdrawal? Please explain.
Have you ever been hospitalized for suicidal thoughts/actions? If so, please list hospital and dates of hospitalization
Rate your mental health on a scale of 1 to 10
1
2
3
4
5
6
7
8
9
10
Poor
Excellent
1 is Poor, 10 is Excellent
Rate your physical health on a scale of 1 to 10
1
2
3
4
5
6
7
8
9
10
Poor
Excellent
1 is Poor, 10 is Excellent
Rate your spiritual health on a scale of 1 to 10
1
2
3
4
5
6
7
8
9
10
Poor
Excellent
1 is Poor, 10 is Excellent
Yes
No
Have you had suicidal thoughts in the past 30 days?
Have you ever tried to kill or harm yourself before?
Medical History
Do you have any allergies? (If yes, please list them)
Current Weight
Current Height
List all current prescription medications and how often you take them(withholding ANY medications from staff during the interview or intake process may be grounds for dismissal and the medications may not be filled). We are not a medical facility.
Current medical problems ( withholding ANY medical condition from staff during the interview or intake process may be grounds for dismissal).
Have you ever received a mental health diagnosis such as Schizophrenia, Bipolar Disorder or Chronic Depression? If so, please specify and list date of diagnosis.
Have you ever been a client at The Potters House? If so, when?
Have you been admitted to a state or private facility in the past for substance/alcohol abuse? If yes, please list date of entry/departure, facility and reason for admittance.
Tobacco History
Do you currently smoke cigarettes?
Yes
No
How many packs per day?
How many years?
Family Background:
Do you have children?
Yes
No
Are your children in your custody?
Yes
No
N/A
Who has custody of your children? If you currently have custody, who would be taking care of your children during your 18-month stay at The Potters House?
List your children and their ages:
*
Personal History
Do you have a history of being abused emotionally, sexually, physically or by neglect? If yes, please describe when, where and by whom.
Highest grade completed?
Are you currently:
Working
Student
Unemployed
Disabled
Retired
Are you currently:
Married
Partnered
Divorced
Single
Widowed
If married, for how long?
Have you ever been involved in a homosexual relationship? Explain.
Have you ever been involved in prostitution?
Have you ever been involved in satan worship, the occult or witchcraft? Explain.
What is your first memory of pain, emotional or physical? Please explain.
What are your top 3 goals upon completing this program?
Please use this section to explain your desire to change and seek treatment. Include details from your past, present, and your hopes for the future. Explain why you chose The Potters House. This essay is a requirement and also a determining factor in your admission, please be honest, open, and put thought into what you are writing.
Judicial Background:
Have you ever been arrested?
Yes
No
Are you currently on probation, parole, out on bond or court ordered to be here? If yes, explain below.
Yes
No
Do you have any outstanding warrants?
Yes
No
If on probation/parole/out on bond please explain the following: Location of probation, charge, how long, upcoming court dates.
Emergency Contact
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Are you willing to give serious consideration to the teaching of Jesus?
Do you realize The Potters House is a non-denominational spiritual program that believes in salvation, Holy Spirit Baptism, speaking in tongues, casting out demons, laying hands on the sick, and raising the dead?
Yes
No
Do you understand that your 18 month commitment is not to us but to God? It is apromise, a vow you are making to him? God’s word says, “It is better to nevermake a vow and break it than to make one at all”.
Yes
No
My signature indicates that I am coming to The Gastonia’s Potters House on my own free will. I hereby agree to cooperate in the program and abide by all rules. Ido assume risks that might by incidental to my stay; and I do hereby for heirs, executors, my administrators, myself or any representatives, release and relinquish forever, any and all claims of any nature whatsoever that may arise out of or in connection with my stay here. I also give The Gastonia’s Potters House permission to release my information/records as the occasion arises. My signature indicates that I have read and accepted the conditions of this application.
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