Preliminary Intake Application

Preliminary Intake Application

Thank you for your interest in Refuge Ministries. Refuge Ministries is a Christ-centered residential recovery and discipleship home for adult women seeking freedom from drug and alcohol addiction and healing from trauma.This application helps us learn a little about you and determine whether Refuge Ministries may be a good fit for your needs. Completing this application does not guarantee admission. A member of our team will contact you to discuss next steps.Please note: Refuge Ministries is not a detox facility, hospital, or medical treatment center. Women who need medical detoxification or a higher level of clinical care may be referred to an appropriate provider before admission.
Full Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Age
Gender (Refuge Ministries only houses women at this time.)
What is the best way to contact you?
Is it safe to leave a voicemail?
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Current Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Emergency Contact Name

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Where are you currently staying?
Why are you seeking recovery at this time?
How long have you been sober? (Refuge Ministries is not a medical detox. All applicants must complete medical detox before admission if needed.)
When did you last use substances?
What is your substance of choice?
Are you currently sober?
Are you currently receiving substance use treatment? If so, where?
Have you ever been in a recovery program ro detox before? If so, where and when?
Do you have children? If so, please list their ages.
If accepted into the program, where will your children stay?
When would you need housing?
Are you currently fleeing domestic violence?
Are you ready to live in a drug and alcohol free home?
Are you willing to participate in random drug and alcohol testing?
Are you willing to participate in recovery meetings, house meetings, classes, and other required Refuge Ministries programming?
Refuge Ministries is a Christ-centered program that includes prayer, Bible study, devotion, church involvement, and Christian discipleship. Are you willing to participate in the faith-based components of the program?
Are you willing to follow house rules, curfew, chores, and program expectations?
Are you willing to work toward employment, education, vocational training, or another approved goal when you reach the appropriate phase of the program?
Do you have any medical, mobility, mental-health, or medication needs that Refuge Ministries should know about when considering whether we can safely support you?
Please briefly explain what accommodations or support you may need.
Have you had thoughts of harming yourself or someone else within the past 30 days?
Are you currently on probation, parole, or under court supervision?
Do you have any upcoming court dates or legal obligations?
Please explain any legal issues you may have:
Are you currently employed?
Do you currently receive any income or benefits?
What would you most like to change about your life during your time at Refuge Ministries?
What are your biggest goals for your recovery?
Is there anything else you would like us to know about you?
Signature
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