By completing this application, I agree to the following:
- I am medically stable. Any individual with ongoing medical issues may be accepted if they are addressing these issues with professional help.
- I have adequate control over my behavior and assessed not to be imminently dangerous to oneself or others.
- I have a desire to remain in recovery from addiction to drugs or alcohol (as applicable)
- I am able and willing to participate in the Mary’s Place program.
- I am able to meet personal needs without assistance; including administration of own medications.
- I agree to program rules and policies including completing a background check.
- I agree Mary’s Place program can contact and very information with those listed on this application including; probation and parole, Wood County Adult Drug Treatment Court, recovery coaches, and employers.
- I agree to complete a drug test analysis upon entry into the program. *A positive result does not necessarily mean I am not be able to participate.
- I can attend effectively to activities of daily living and have no cognitive impairments that will prevent me from understanding and participating in the program.
- I do not have ongoing medical ailments which require a more intensive level of monitoring and care then can be provided by Mary’s place.
- I do not have criminal history that includes violent behavior and/or acts.
- I have not been convicted of a sex-related crime and/or I am not required to register with the Wisconsin Sex Offender Registry.
I agree to the rules and polices of the Mary’s Place of Central Wisconsin program and agree to a background check including CCAP. Non-authorization will deny my entry into the program.
I understand this is a program-based organization with rules and program fees. I agreed to abide by them.
I have provided this information to the best of my ability and understand that I may be asked to provide verification of the information described within this application. I authorize the verification of the information provided on this form.
I certify that my answers are true and complete to the best of my knowledge.
If this application results in acceptance into the program, I understand that false or misleading information in my application or interview may result in my discharge at any time.
I understand that completing an application does not guarantee my acceptance into the Mary’s Place program