Valley Rescue Mission

Do you know or are you acquainted with anyone connected to Valley Rescue Mission?*
Why are you applying to a recovery Program at this time?*
What are your immediate needs?*
What are your present goals?*
What are your strengths?*
What are your weaknesses?*

Do you have children who will need care during your rehabilitation?*
Can you make arrangements for a responsible party to care for your children for nine months?*
Who is this person/what is their relationship to you?*
List any Children and DOB*
Emergency Contact Name*
Emergency Contact Relationship*
Emergency Contact Address*
Emergency Contact Phone Number*
Please enter a valid phone number.
Do you have family in Muscogee County or the immediate area?*

List drugs you have tried*

Have you ever experienced any of the following types of abuse?*

What is the highest level of education completed?*
Are you a Veteran?*
Are you employed?*
Last residence.*
Ever received housing assistance?*
Do you owe the Housing Authority money?*
Are you presently homeless?*
Are you currently receiving Medicare/Medicaid, disability or other Government aid?*
Are you on food stamps/EBT?*
If selected for residence in this program, is there anything that we should know about you that would hinder your ability to sweep, mop, lift, mow, or do normal household chores?*
NOTE: This center is not a medical or psychiatric facility: therefore, prospective clients must be medically, as well as, psychiatrically cleared prior to admission. The requested medical information within this application for consideration of admission form is vitally important and is required before a decision can rendered as to the appropriateness of our facility for prospective clients. If mental health evaluation / documentation is requested, that also must be received before a final decision can be made regarding placement in the Recovery Program. If, within 30 days of admission, it is noted that the client is inappropriate due to medical or psychiatric reasons about which we were uninformed prior, this facility reserves the right to refer the client to another facility or back to the referring agency.
Signature Name*
Should be Empty:

Biosychosocial Assesment