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THE GASTONIA POTTERS HOUSE
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Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Date
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Month
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Day
Year
Date
Date of Birth
Gender
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Requested Entry Date
What drugs are you currently using and how much?
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What drugs have you used in the past and how much?
Is there a history of substance abuse/ alcoholism in your family? Please describe
Age of first drug/alcohol use?
Type a question
Have you ever been hospitalized for suicidal thoughts/ actions? If so please list the hospital and the dates.
Rate your mental health on a scale from 1-10
Rate your physical health on a scale of 1-10
Rate your spiritual health on a scale of 1-10
Have you had any suicidal thoughts in the last 30 days?
Have you ever tried to harm/ kill yourself before? If so when?
Do you have any allergies? If so please list them.
Current weight?
Current Height?
List ALL current medications that you are taking and how often. Failure to tell the staff at GPH about ANY medications that you are on during the intake process may result in immediate dismissal.
Current medical problems? Failure to tell GPH staff about ANY medical problems that you have during the intake process may result in immediate dismissal.
Have you ever received a mental health diagnosis such as Schizophrenia, Bipolar Disorder or Chronic Depression? If so , please specify and list the date of diagnosis.
Have you ever been a client at The Potters House before? If so when?
Have you ever been admitted to a state or private facility in the past for substance/ alcohol abuse? If yes, please list the dates of entry/ departure, facility and the reason for admittance.
Do you currently smoke cigarettes? If so, how many packs per day? How many years?
Do you have children? Are your children in your custody? If not, who has custody of your children? If they are in your custody, and you get accepted into our program who would take care of your children until you completed the program? What are the ages of your children?
Do you have a history of being abused emotionally, physically, sexually or by neglect? If yes, please describe when, where and by whom.
Highest grade completed?
What is your current employment status?
Are you divorced / married/ single or 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 open, and put thought into what you are writing.
Have you ever been arrested? When? Why?
Are you currently on probation or parole, out on bond or court ordered to be here? If yes, please explain below.
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Do you have any outstanding warrants?
Emergency Contact
Emergency Contact 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?
Do you understand that your 18 month commitment is not to us but to God? It is a promise, a vow you are making to Him? God's word says, " It is better to never make a vow and break it than t make one at all."
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 the rules. I do assume risk 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 accept the conditions of this application.
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