Bethel House Women's Admissions
Date of Application
-
Month
-
Day
Year
Date
Who is filling out this form?
*
First Name
Last Name
Emergency Contact
Relationship to Applicant
Applicant Name
*
First Name
Middle Name
Last Name
Birth Date
-
Month
-
Day
Year
Date
Gender
Please Select
Male
Female
Height & Weight
Social Security Number
Veteran?
Yes
No
Do you have your GED or High School Diploma?
Yes
No
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What hometown are you originally from?
Email
example@example.com
Mobile Number
Please enter a valid phone number.
Format: (000) 000-0000.
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Work Number
Please enter a valid phone number.
Format: (000) 000-0000.
Home Church
Minister's Name
Which location are you interested in?
Please Select
Bethel House (Women)
Gideon House (Men)
How did you hear about us?
What form of ID do you have?
Drivers License
State ID
No ID
Drivers License Number
State ID Number
What is you sexual orientation?
Straight
Gay
Bisexual
Are you...
Single
Married
Divorced
Separated
Widowed
Dating
Common Law Marriage
Could you be pregnant at this time?
Yes
No
I'm not sure
How many children do you have?
Are you required to pay child support?
Yes
No
Can you read and write?
Yes
No
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Next
LEGAL QUESTIONS
Do you have any pending court dates?
Yes
No
If yes, where at and what is the current status of the case?
Are you currently on probation or parole? If yes, please include your Probation Officer's Name, Location, Phone Number, and Email.
Do you have any open warrants?
Yes
No
If yes, where and for what crimes?
Have you ever been convicted of a sex crime?
Yes
No
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DRUG / ALCOHOL HISTORY
What are you currently using and/or struggling with?
When was the last time you used?
-
Month
-
Day
Year
Date
How long have you been consecutively using for?
Are you in need of a detox before starting the program?
Yes
No
Are you using any nicotine products?
Yes
No
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MEDICAL HISTORY
Do you have medical insurance?
Yes
No
If yes, what is it?
Do you have any of these medical conditions? (Check all that apply.)
Hepatitis
HIV/AIDS
STD's
TB
Asthma
High Blood Pressure
Diabetes
Epilepsy / Seizures
Other
If you checked any boxes, please explain:
Are there any other medical conditions not listed that we need to be made aware of that may hinder you from working while in the program?
Please list any allergies you may have:
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MENTAL HEALTH MHMR
Have you ever been diagnosed with any of the following? (Check all that apply.)
Depression
Anxiety
PTSD
Bipolar Disorder
Schizophrenia / Hearing voices
Eating Disorder
Cutting / Self Harm
None
Other
Have you ever been suicidal?
Yes
No
If yes, please explain the circumstance:
Please list all medications you are currently taking, including prescription and over the counter medication.
You are required to have a 90 day supply of your medication upon admission. Are you able to obtain these before your entry date?
Yes
No
Not Sure
We do not accept anyone who receives any MENTAL HEALTH payments. Are you currently receiving any of the following?
Unemployment
Social Security
Disability
Other
If yes, then what and how much do you receive? (This will be further discussed with your intake counselor as it relates to payment and your induction fee before being accepted.)
New Creation Restoration Centers requests a one-time, non-refundable induction fee of $1,600. Please indicate if/how your payment(s) will be made below.
Full - $1,600
2 x $800
3 x $534
Payment Plan
**Non-payment disclosure** If full or partial induction fee payment(s) are not made during the duration of the program, New Creation Restoration Centers is not obligated to and will not provide travel expenses if an individual enrolled in the program is dismissed for violating the program's policies and procedures or chooses to leave against ministerial counsel. Do you understand the parameter of this disclosure?
Yes
No
**Medical Disclosure** We are NOT a Medical Facility. If you are due for a doctors checkup or are in need of dental work, we strongly advise that you take care of that before entering our program. YOU WILL NOT see a doctor for at least 90 days unless it's an emergency. The only meds that you are allowed to bring are the meds that we have talked about in this interview. If you claim to need a medication that you did not mention in your interview you will not be allowed to get that medication. Expect discomfort once your body is clean and sober you will feel pain that your DOC was numbing. After going over this interview are their any further questions you have for me at this time? The interview is now completed. If you are interested in coming to our program, I will email you the Rules of the Program for you to read and sign before arriving. Do you understand everything that we have talked about today and what's involved?
Yes
No
Please provide an Email Address or Cell Phone Number where the Rules of the Program can be sent for you to review.
Personal Notes Post Interview
Submit
Should be Empty: