Application

SHALOM RECOVERY CENTER APPLICATION

"For I know the plans I have for you, declares the Lord. Plans for welfare and not for calamity to give you a future and a hope."

Jeremiah 29:11

Shalom Recovery Center requires the following medical tests before being accepted: HIV, VD, and pregnancy. These can be obtained at the health department.

Shalom Recovery Center offers 12 week, 24 week, 36 week sessions. Our fee is $2,400 for each 12 week session. The fee is nonrefundable. Applicants must be interview prior to consideration and acceptance.

Today's Date*

MonthDayYear

Applicant Phone Number*

Applicant full name (first, middle, and last)*

Applicant Birthdate*

MonthDayYear

Applicant Age*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Marital Status*

Level of Education:*

Emergency Contact 1 Name*

Relationship *

Phone Number*

Emergency Contact 2 Name

Relationship

Phone Number

Emergency Contact 3 Name

Relationship

Phone Number

Please list your children's names, sex, and ages here:*

Are any of the children in DSS custody?*

YesNo

If yes, where?

Upcoming court date(s):*

Name and phone number of Case Worker:*

Who is caring for your children?*

Relationship*

Please list the dates you last used the following drugs:

Crack/ cocaine*

Marijuana*

Alcohol*

Meth/ Amphetamines*

Heroin*

Abuse of prescription meds?*

YesNo

If yes, please list them here:

Date and length of longest period of sobriety:*

Age you began using drugs and alcohol:*

How long have you been an addict/ alcoholic?*

Have you previously been treated for drug/ alcohol addiction?*

YesNo

If yes, when and where?

Reason for leaving:*

Are you on parole?*

YesNo

Are you on probation?*

YesNo

If yes, in what city?

Name of probation/parole officer:

If currently incarcerated, list institution, charges, and release date:

Pending charges?

YesNo

Court date (if you have one)

MonthDayYear

Charges:

Honest answers to these questions will not disqualify you from the program.

What is your current state of health?*

ExcellentGoodFairPoor

Are you pregnant?*

YesNo

Do you have any allergies to food, etc? Please list:*

Are there any health or mental health problems you are currently dealing with?*

List any prescription or non-prescription medications you are taking at this time.*

Can you get refills?*

YesNo

Do you have any handicaps or disabilities?*

YesNo

If yes, please describe:

Have you ever attempted suicide?*

YesNo

When?

Do you feel suicidal now?*

YesNo

Have you ever been admitted to a mental health facility?*

YesNo

If yes, when?

If yes, where?

Are you presently working with mental health professionals?*

YesNo

Do you have any diagnosed mental disorder? If so, please list:*

Last psychiatric visit?

Shalom Recovery Center is not a medical center and cannot give medical care. Who will be responsible for your medical expenses if you need medical care while at Shalom Recovery Center?*

Who will be responsible for your fee at Shalom?*

Relationship:

Do you have:*

Medical InsuranceMedicareMedicaidNo insurance

Are you on Disability?*

YesNo

If yes, for what?

How much disability do you receive per month?

Are you presently employed?*

YesNo

If yes, where?

Are you a Christian?*

If you practice another religion, please let us know here:

Have you been baptized?*

YesNoI don't know

If yes, when?

My signature indicates that I am applying for residence at Shalom Recovery Center of Shalom House Ministries on my own free will. I agree to cooperate in the work program and obey all the rules. I assume any and all risks incidental to my residence at Shalom Recovery Center. Applicant shall be responsible to insure Applicant's personal property against loss or damage. Applicant releases Shalom House Ministries from liability for and agrees to indemnify Shalom House Ministries against all losses incurred by Shalom House Ministries, including, but not limited to, attorney's fees, as a result of: (a) Applicant's failure to fulfill any condition of this Lease; (b) any damage or injury happening in or about the Property to Applicants or Applicant's invitee or licensees or such persons' property, except where such damage or injury is due to gross negligence or willful misconduct of Shalom House Ministries; (c) Applicant's failure to comply with any requirements imposed by any governmen authority; and (d) any judgment, lien or other encumbrance filed against the Property as a result of Applicant's actions. On behalf of my heirs, executors, administrators, myself, and any representative, I hereby release forever any and all claims arising out of or in connection with my residence at Shalom Recovery Center. I also give Shalom House Ministries, Inc. permission to release information and records as required by law.

My digital signature indicates that I have read or have had this application read to me and that I accept the conditions of this application.

Initials*

Date*

MonthDayYear

General Information

Emergency Contact Information

Drug Use

Legal Issues

Medical History

Religious History