ADULT REHABILITATION PROGRAM

Please fill out this application COMPLETELY.
DO NOT LEAVE ANY BLANK SPACES.
Print big and clearly.
For Yes answers, write Y and for No answers, write N.
Write N/A on questions that do not apply to you.
Please read and sign Eligibility Requirements before returning your application.

Intake Requirements

If you are accepted and scheduled for an intake, at the time of your intake you will need:

TO BE ABLE TO PASS A DRUG TEST IN ORDER TO BE ADMITTED INTO THE PROGRAM
PHOTO ID (driver license/ID card, jail booking photo, or a copy of such)
SOCIAL SECURITY CARD (or a copy)
Latest TB test result taken within the last 6 months (can be obtained from jail or medical office)
To be ready and able to work the required 8 hours a day, 5 days a week
- Work therapy is a key component of the program.

Today's Date

Date

Full Name

Date of Birth

Date

Age

Gender

Current Address (this is a jail address if you are in custody)

Phone Number or Contact Phone Number (probation officer/public defender if you are in custody)

Briefly explain your present situation and how you got there:

Are you willing to commit to a six month rehabilitation program?

yes no

Are you related to or have you had a sexual relationship with anyone currently in this facility?

yes no

If so, who?

Have you ever attended a Salvation Army drug and/or alcohol rehabilitation program?

yes no

If yes, where?

When?

Please select the following if you are currently on or will be on:

Probation ACS Parole

If you selected any of the choices, in which county will you be on?

What are your current charges?

If your current charges are for probation/parole violations, what was your original offense?

Are you required to register as a:

Drug offender? Sex offender?

Have you ever been convicted of an arson crime?

*NOTE: We are not a medical facility. You may be ineligible if you have a pre-existing medical condition.

Are you pregnant? (female applicants only)

Are you currently taking medications(s)?

If yes, please list current medications:

Have you ever had a psychological/psychiatric exam or treatment?

If yes, when was this?

What was your diagnosis, if any?

Are you currently suicidal?

Do you or have you in the past experience(d) suicidal thoughts?

Do you need immediate dental care?

Do you need immediate vision care?

*If yes, you need to have these matters addressed before entering the program. Otherwise, you will be required to wait until after your blackout period to address any medical needs. Failure to comply with this policy will result in termination from the program.

Do you have a copy of your current TB test (within the last six months)?

Do you have any other medical conditions? If yes, please descibe:

Have you experienced any past injuries that may be aggravated by working 40 hours per week? If yes, please explain

Are there any other physical/health issues that would prevent you from working at 40 hour week? If yes, please explain:

Are you able to lift 50 lbs.?

Do you drink alcohol? If yes, how long have you been drinking?

How often and how much do you drink?

When was the last time you drank?

What is/are your drug(s) of choice?

How often and how much do you usually use?

Do you have "clean" time? If yes, how much?

Does anyone in your family have a history of substance abuse? If yes, who?

Does your significant other have a history of substance abuse?

All piercings MUST be removed prior to entry. (This includes surface/transdermal piercings **Men: Hair must be off the collar and ears. No facial hair with the exception of a mustache. **Women: Makeup is not allowed during work therapy.

Are you willing to follow these standards?

Please describe yourself

In addition to gaining and maintaining your sobriety, what do you hope to accomplish during your time in the program?

Participation in the program requires strict adherence to rules. How do you feel about following rules and being re directed?

How do you feel about working with other people to help you resolve some of the problems you may have (including Salvation Army staff/counselors and other program participants)?

Please read the following statement and sign below in agreement:

I affirm that I have answered all questions in this application to the best of my ability. I further state that

Ihave answered all questions as accurately and completely as possible. I understand that omitting or concealing

information may result in my discharge from the program.

Signature

Clear

Date

"Please read the information on the following pages carefully. Be sure to sign and date after reading.**

To enter treatment at The Salvation Army, Chico ARP you must be:
- At least 18 years of age.
- Fully detoxed from all substances. This includes narcotic prescription medications. You must pass a urinalysis on the day of your intake.
- Capable of participating in a Work Therapy Assignment (WTA) for 8 hours per day, 5 days per week. This will require standing, walking, and/or lifting up to 50 lbs.
- Willing to work on all recovery issues.
- A minimum of 30 day supply of medication.
- No court our medical appointments for 30 days.
If you have been convicted of a sexual offense or arson crime, you are ineligible for this program.

Program Length: The Chico Adult Rehabilitation Program is a six-month residential program. Program length is assessed on an individual basis and may be extended due to conduct or performance issues.

Acceptance Letters: Letters of acceptance require regular check-in from the applicant. Applicants must check in regularly with the intake office (recommended twice weekly Applicants will be removed from the waiting list if they have not corresponded with intake within 45 days.

Personal Property: The Salvation Army Chico Adult Rehabilitation Program will provide all necessary personal items. Socks (10 pair), underwear (10 pair), undershirts (7), bras (5), and comfortable shoes (2 pair, no open toe) are permitted to be brought in with you at intake. Hygiene products must conform to program guidelines. All other personal property will be stored at the risk of the program participant for a maximum of 30 days after separation from the program.

Employment / School / Court Obligations: The Adult Rehabilitation Program does not permit outside attendance of coursework, employment, or court ordered obligations.

Medical: If you need medical treatment during your initial 30 day blackout period, you will be terminated from the program. If you require prescription medication, you must have a 60 day supply available at the time of your intake. All prescription medications must be approved by program staff prior to admission. All medical and dental appointments must be handled prior to admission or after the initial blackout period.

Pre-existing Conditions: If you are diagnosed with a pre-existing medical or mental health condition, this may prevent you from admission into the program. The Salvation Army Chico Adult Rehabilitation Program is not a medical facility and is not staffed with medical or health professionals.

Medi-Cal/CalFresh: In accordance with California state law, while in the Salvation Army program, applicants will apply for CalFresh benefits in Butte County to help offset food costs. If you currently have CalFresh, your case will be transferred to The Salvation Army Chico Adult Rehabilitation Program address. In addition, applications will also apply for County Medi-Cal health insurance. If you already have CalFresh and/or Medi-Cal, please bring your CalFresh EBT card and/or Medi-Cal insurance card with you to your intake appointment

Please sign below to show you have read and agree to eligibility requirements and conditions.

Clear

Date

**Continue onto the next page for directions on how to submit your application and to learn more about the Salvation Army Adult Rehabilitation Program.**

Return this application in-person or by mail, e-mail, or fax to:

Jodene Setera, Program Director

Address:

Jodene Setera, Program Director

13404 Browns Valley Drive

Chico, CA 95973

Email:

jodene.setera@usw.salvationarmy.org

Fax:

(530) 898-8116

Phone:

(530) 342-2199

The Salvation Army has the largest addiction treatment program in the nation. The Chico ARP offers a six-month rehabilitation program for addicts and alcoholics. The program consists of individual and group counseling, drug and alcohol education classes, 12-step meetings and studies, and psychoeducational groups such as Anger Management, Codependency, Relapse Prevention, and Self-Esteem. Work Therapy Assignment is a key component to the program. Each participant is given a 40-hour-per-week job assignment to help build or instill a solid work ethic. Additionally, there are written homework assignments designed to help with self- reflection and insight. Our program is based on in-depth Christian spiritual principles. Bible studies and chapel services are designed to facilitate spiritual growth and are offered on a non-mandatory basis. The Chico ARP

has a capacity for 30 men and 20 women. Interested parties need to call the intake counselor regarding bed

availability. Always leave a message with you name and contact phone number so that we can return your call.

Full Name

Please complete this questionnaire.

Do you have any court dates of medical appointments within the first 30 days of treatment?

LIST ALL MEDS YOU ARE CURRENTLY TAKING:

Do you have 60 days of medication to bring to you?

Entering this program requires you make at least a six month commitment

If there is an urgent medical or court issue during your blackout period, you may be discharged from the program

No personal vehicles are allowed to be parked/stored on Salvation Army property

No electronic devices are allowed on Salvation Army property and we will not store your device for you

Only items on the approved personal property list will be permitted

No transdermal piercings are permitted

No jewelry, except for a wedding ring or medical bracelet, will be permitted

Do you have a behavioral health/mental health diagnosis? If so, what is your diagnosis?

Have you been prescribed medication for this diagnosis? If so, what?

Do you have any medical condition(s) that would prevent you from participating in 40 hours of work therapy per week?

Can you lift up to 50 lbs.?

Have you ever been convicted of an arson or sex crime?

Do you have any gang affiliation? Or actively prospecting for a gang?

Do you have a personal relationship with any staff or current beneficiaries at the ARP?

THE SALVATION ARMY

ADULT REHABILITATION PROGRAM - CHICO, CA

Criminal Background

Medical/Mental Health Inquiry

Substance Abuse History

Eligibility Requirements

Additional Conditions of Acceptance

Submitting Application

About Us

Please initial next to each of the following to confirm that you are aware that: