• God's Way Home Intake Application

    PLEASE READ THE FOLLOWING STATEMENT BEFORE COMPLETING THIS APPLICATION: The only MAT that we can currently accept at God's Way Home is the Vivatrol shot. At this time, we cannot accept you into our program if you are on Suboxone, Sublocade, Subutex, or Methadone. Also, we cannot accept sex offenders or arsonists.

  • Applicant Information

  • Have you ever been known by an alternate name?
  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.

  • Housing and Program History

  • Do you have any concerns with sharing a room?*
  • Are you able to perform household chores?*
  • Would you be interested in living at a faith-based or spiritually-based recovery house if there was space available for you?*
  • What best describes your current living situation?*
  • Have you ever been in another housing program within the last 90 days?*
  • When would you like to move in?*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Have you previously applied to God's Way Home?*
  • How long would you hope to stay at God's Way Home?*
  • Are there any issues that could prevent you from completing the program?*

  • Emergency/Family Contact

  • Format: (000) 000-0000.

  • Substance Use History

  • What is your sober or clean date?*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Medical and Health

  • Do you have any allergies?*
  • Are you currently under the care of any of the following provider types?*
  • Do you have any physical health or medical conditions or disabilities?*
  • Do any of the following apply to you?*
  • Do you have a history of seizures?*
  • Do you have HIV?*
  • Do you have any upcoming appointments or ongoing physical needs?*
  • Do you have any medical equipment?*
  • Do you have any mental health issues or diagnosis?*
  • Do you have a history of self-harm?*
  • Have you ever experienced any suicidal ideations, attempts, or received in-patient treatment for self-harming behaviors?*
  • Do you have an eating disorder or body image disorder?*
  • Do you have a need for mental health services?*
  • Have you ever gotten in an altercation with a peer?*
  • Are you experiencing shortness of breath, coughing, fever, or other symptoms of coronavirus and/or flu?*
  • Are you currently on any form of Medication-Assisted Treatment (MAT)?
  • Are you currently using any prescription medications?*
  • Are you currently using any over-the-counter medication?*
  • Do you have enough prescriptions to last you for the next two weeks?*
  • Are you currently in a treatment program?*
  • Have you ever been through any other treatment programs previously?*
  • Do you have a learning disability or difficulty reading?*
  • Do you identify as a person with a disability or other chronic condition?*

  • Legal and Criminal History

  • Are you currently involved in any legal proceedings or criminal justice issues?*
  • Do you have any court-ordered treatment requirements?*
  • Do you have any pending sentencing or possible jail time upcoming?*
  • Have you ever been charged or convicted of arson?*
  • Have you ever been charged or convicted of abuse or neglect of any person, including a disabled person, senior, or child?*
  • Are you affiliated with any gang?*
  • Select all legal requirements that apply*
  • Are you required to register as a sex offender?*
  • Are you required to register with any other authority for any other reason?*

  • Employment and Transportation

  • Are you able to work?*
  • Are you currently employed?*
  • Are you willing to work 32 hours a week of gainful employment?*
  • Do you have a valid driver's license?*
  • What is your primary mode of transportation?

  • Additional Information and Uploads

  • Should be Empty: