INSPIRATION APPLICATION & INTAKE

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INSPIRATION RECOVERY PROGRAM

To download a printable version of this application, please click on the link below, print out and complete the form. Then mail it or scan and email it to the relevant address listed below. Thank you.

173 W. Oak St.
Butler, IN 46721
info@inspiration-ministries.org

Link to Printable Inspiration Recovery Program Application

Otherwise click "NEXT"

to continue on to the online application.

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A.1 DATE OF APPLICATION* This field is required.

Date

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A.2.1 WHAT IS YOUR PROJECTED DISCHARGE OR RELEASE DATE?

Date

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A.2.2 WHEN IS YOUR NEXT COURT DATE?

Date

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A.3 Which Program are you applying for?* This field is required.

Men

Women

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A.3.1 Are you applying for the Huntington House in Huntington, IN?

Yes

No

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A.4 Have you been in an Inspiration Ministries Recovery Program before?* This field is required.

Yes

No

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A.4.1 Have you been at the Huntington House or in an Inspiration Ministries Recovery Program before?* This field is required.

Yes

No

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Explain what caused you to leave the program the first time and why will that not be an issue this time.

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Explain how this time will be different from the first time you were in the program.

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Residents that leave the program must wait 30 days to apply for re-entry into the program. The re-entry application and subsequent interviews require more information and transparency from the applicant. Therefore, we have some special questions for you to answer.

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B.1.1 FIRST NAME* This field is required.

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B.1.2 LAST NAME* This field is required.

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B.2 DATE OF BIRTH* This field is required.

Date

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B.3 GENDER* This field is required.

Male

Female

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B.3.1 MALE GENDER

Male

Female

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B.3.2 FEMALE GENDER

Male

Female

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B.4 RACE

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B.5 CURRENT LOCATION* This field is required.

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B.6 CURRENT MAILING ADDRESS* This field is required.

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B.7 CITY* This field is required.

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B.8 STATE* This field is required.

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B.9 ZIP* This field is required.

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B.10 PHONE NUMBER WHERE WE CAN REACH YOU* This field is required.

Please enter a valid phone number.

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Email

example@example.com

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B.11 SOCIAL SECURITY NUMBER* This field is required.

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B.12 MOTHER'S MAIDEN NAME

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C.1 ARE YOU CURRENTLY BATTLING AN ADDICTION?* This field is required.

Yes

No

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C.1.1 IF YES, EXPLAIN

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C.2 ARE YOU WILLING TO REMAIN ALCOHOL AND DRUG FREE WHILE IN THE INSPIRATION PROGRAM?* This field is required.

Yes

No

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C.3 PRIMARY DRUG CHOICE* This field is required.

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C.3.1 HOW USE? SMOKED, ORAL, INJECTION, ETC* This field is required.

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C.3.2 FREQUENCY (DAILY, WEEKLY, MONTHLY)* This field is required.

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C.3.3 AGE WHEN FIRST STARTED

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C.4 SECOND DRUG CHOICE

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C.4.1 HOW USE? SMOKED, ORAL, INJECTION, ETC

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C.4.2 FREQUENCY (DAILY, WEEKLY, MONTHLY)

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C.4.3 AGE WHEN FIRST STARTED

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C.5 THIRD DRUG CHOICE

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C.5.1 HOW USE? SMOKED, ORAL, INJECTION, ETC

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C.5.2 FREQUENCY (DAILY, WEEKLY, MONTHLY)

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C.5.3 AGE WHEN FIRST STARTED

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C.6 HAVE YOU EVER LIVED IN ANOTHER RECOVERY/HALF-WAY HOUSE?

Yes

No

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C.6.1 IF YES, WHERE?

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C.6.2 HOW LONG & WHAT WAS THE RESULT?

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C.7 LONGEST YOU HAVE BEEN SOBER/CLEAN IN THE LAST 12 MONTHS?* This field is required.

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D.1 WHO REFERRED YOU TO INSPIRATION MINISTRIES? (SELF, LAWYER, SUPERVISION OFFICER, TREATMENT CENTER, FRIEND, FAMILY, ACQUAINTANCE)* This field is required.

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D.2 HOW DID YOU MAKE INITIAL CONTACT? (APPOINTMENT, PHONE, WALK-IN, MAIL APPLICATION, SUPERVISION OFFICER)

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D.3 DO YOU KNOW ANYONE CURRENTLY ENROLLED IN THE PLUS ONE PROGRAM?

Yes

No

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D.3.1 IF YES, WHO

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D.3.2 WHAT IS YOUR RELATIONSHIP TO THEM?

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E.1 DO YOU HAVE A RELATIONSHIP WITH JESUS CHRIST?* This field is required.

Yes

No

Not Sure

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E.2 DO YOU HAVE A HOME CHURCH?

Yes

No

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E.2.1 IF SO, WHERE?

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E.3 Do you understand that Inspiration is a faith-based program?

Yes

No

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OLD 3. BRIEFLY EXPLAIN YOUR SPIRITUAL JOURNEY (Optional)

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F.1 HIGHEST COMPLETED LEVEL OF EDUCATION? (9, 10, 11, HS, GED, BA, MA, TRADE)

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F.1.1 IF TRADE, WHAT SKILL?

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F.2 ARE YOU INTERESTED IN FURTHERING YOUR EDUCATION?

Yes

No

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F.2.1 IF SO, HOW?

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F.3 ARE YOU CURRENTLY EMPLOYED?

Yes

No

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F.3.1 IF SO, WHERE?

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F.4 LONGEST YOU’VE KEPT THE SAME JOB?

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F.5 HOW MANY JOBS IN THE LAST 12 MONTHS?

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G.1 DO YOU HAVE A CURRENT DRIVER'S LICENSE?* This field is required.

Yes

No

Suspended

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G.1.1 IF NO, WHY NOT?

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G.2 DO YOU HAVE A STATE ID?

Yes

No

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G.3 DO YOU HAVE A SOCIAL SECURITY CARD?* This field is required.

Yes

No

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G.4 DO YOU HAVE YOUR BIRTH CERTIFICATE?* This field is required.

Yes

No

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H.2 HOW MANY TIMES IN PRISON?

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H.3 LONGEST JAIL/PRISON TERM?

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H.4 DO YOU HAVE A PENDING CASE OF ANY KIND?

Yes

No

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H.4.1 CURRENT CHARGE?

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H.4.2 NAME OF LAWYER?

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H.4.3 NAME OF JUDGE?

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H 5 Corrections Type

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H.5.1 IF YES, DOC #:

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H.5.2 IF YES, WHAT COUNTY?

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H.5.3 IF YES, WHAT IS THE NAME OF YOUR SUPERVISOR

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H.6 DO YOU HAVE TO REGISTER WITH THE SHERIFF'S OFFICE FOR ANY PAST OFFENSES?* This field is required.

Yes

No

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H.6.1 IF YES, WHAT CHARGE?

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H.7 PLEASE USE THE FOLLOWING QUESTIONS TO LIST YOUR

TWO MOST RECENT ARRESTS:

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MOST RECENT ARREST:

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H.7.1 MONTH/YEAR

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H.7.2 CHARGES

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H.7.3 COUNTY/STATE

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H.7.4 SENTENCE

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H.7.5 SUPERVISION

Probation

Parole

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H.7.6 OFFICER?

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H.7.7 PHONE

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H.7.8 HOW OFTEN DO YOU MEET?

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H.7.9 DRUG TESTED?

Yes

No

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H.7.10 CAN WE MAKE A PHONE CALL TO YOUR PROBATION OFFICER?

Yes

No

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SECOND MOST RECENT ARREST:

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H.7.11 MONTH/YEAR

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H.7.12 CHARGES

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H.7.13 COUNTY/STATE:

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H.7.14 SENTENCE

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H.7.15 SUPERVISION?

Probation

Parole

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H.7.16 OFFICER?

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H.7.17 Phone

Please enter a valid phone number.

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H.7.18 HOW OFTEN DO YOU MEET?

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H.7.19 DRUG TESTED?

Yes

No

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H.7.20 CAN WE MAKE A PHONE CALL TO YOUR PROBATION OFFICER?

Yes

No

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I.1 ARE YOU CURRENTLY RECEIVING TREATMENT FROM A MENTAL HEALTH PROVIDER?

Yes

No

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I.1.1 IF YES, WHERE?

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I.2 IF NO, HAVE YOU EVER RECEIVED TREATMENT FROM A MENTAL HEALTH PROVIDER?

Yes

No

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I.2.1 IF YES, WHERE?

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I.3 DO YOU TAKE PRESCRIPTION DRUGS?* This field is required.

Yes

No

Other

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I.3.1 IF YES, EXPLAIN

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I.4 HAVE YOU EVER RECEIVED A MENTAL HEALTH DIAGNOSIS?

Yes

No

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I.4.1 IF YES, WHAT?

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I.5 HAVE YOU EVER RECEIVED A DIAGNOSIS FOR A PHYSICAL DISEASE, DISORDER, OR DISABILITY?

Yes

No

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I.5.1 IF YES, WHAT?

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I.6 ARE YOU ON ANY PRESCRIBED MEDICATIONS?

Yes

No

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I.6.1 IF YES, WHAT?

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I.7 Are you currently on Suboxone?* This field is required.

Yes

No

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I.7.1 How many mg of Suboxone do you currently take per day?

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At the Inspiration Program, we are accepting people who are on NO MORE THAN 8mg of Suboxone per day.

If you are currently on more than 8mg daily, you will need to taper down to 8mg before you will be accepted.

After entering the program, phone and work privileges will be extended once Phase 1 is completed and you have FULLY tapered OFF of Suboxone.

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I.7.2 Do you agree to adhere to this policy?

Yes

No

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I.8 ARE YOU ABLE TO PROVIDE A 30 DAY SUPPLY OF ALL ABOVE MEDICATIONS?* This field is required.

Yes

No

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I.8.1 WHICH MEDICATIONS WILL YOU NOT HAVE A 30 DAY SUPPLY FOR?

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I.9 WHEN WAS YOUR LAST PHYSICAL EXAM?

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I.10 ARE YOU PHYSICALLY IN GOOD HEALTH?

Yes

No

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I.11 DO YOU HAVE ANY PHYSICAL LIMITATION WITH STAIRS, STANDING OR SITTING?* This field is required.

Yes

No

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I.11.1 IF YES, EXPLAIN

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I.12 ARE YOU CURRENTLY OR COULD YOU POSSIBLY BE PREGNANT?

Yes

No

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I.12.1 IF YES, HOW FAR ALONG?

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J.2 DO YOU HAVE FAMILY SUPPORT?

Yes

No

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J.3 LAST FAMILY CONTACT? WHO & WHEN?

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J.3.1 END RESULT OF LAST FAMILY CONTACT?

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J.4 DO YOU HAVE CHILDREN?

Yes

No

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J.4.1 IF YES, NAMES & AGES ( HUNTINGTON APPLICANTS: PLEASE PUT AN * AFTER THE NAMES OF THE CHILDREN WHO WILL STAY WITH YOU IN THE HOME. )

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K.1 DO YOU HAVE HEALTH INSURANCE?

Yes

No

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K.2 DO YOU HAVE FOOD STAMPS?

Yes

No

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K.3 DO YOU RECEIVE DISABILITY?

Yes

No

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K.4.A DO YOU PAY CHILD SUPPORT?

Yes

No

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K.4.B DO YOU RECEIVE CHILD SUPPORT?

Yes

No

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K.4(A,B).1 IF YES, HOW MUCH?

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K.5 DO YOU HAVE ANY UNPAID/CURRENT COURT OR SUPERVISION FEES?

Yes

No

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K.5.1 IF YES, HOW MUCH?

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K.6 ARE YOU A VETERAN OF THE ARMED FORCES?

Yes

No

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K.7 DO YOU HAVE A FAMILY MEMBER IN THE MILITARY?

Yes

No

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RECOVERY WORKS IS A STATE PROGRAM THAT PROVIDES FUNDING FOR THOSE ELIGIBLE TO PARTICIPATE IN TREATMENT & RECOVERY SERVICES.

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L.1 WOULD YOU LIKE TO HEAR MORE ABOUT RECOVERY WORKS?

Yes

No

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L.2 ARE YOU INTERESTED IN CONNECTING WITH A RECOVERY WORKS CONSULTANT?

Yes

No

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L.3 Are you currently an interested party in a CHINS case?* This field is required.

Yes

No

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L.4 Are you currently an involved party in a DCS case?* This field is required.

Yes

No

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M.1.1 STABLE HOUSING

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M.1.2 SPIRITUAL GROWTH

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M.1.3 RECOVERY

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M.1.4 FAMILY RESOLUTION

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M.1.5 FURTHER EDUCATION

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M.1.6 CHURCH FELLOWSHIP

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M.1.7 OBTAINING A JOB

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M.1.8 MENTORING / LIFE COACHING

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M.1.9 TRANSPORTATION

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M.2 WHEN DO YOU WANT TO MOVE-IN?

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M.3 HOW LONG DO YOU THINK YOU NEED TO BE A RESIDENT WITH THE PLUS ONE PROGRAM?

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M.4 WHAT ARE YOUR GOALS AND OBJECTIVES WHILE A RESIDENT IN THIS PROGRAM?

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M.5 WHAT WOULD BE YOUR IDEAL EXIT PLAN ONCE YOU COMPLETE THE PROGRAM?

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Dismissal Contingency: The Inspiration Recovery Program is committed to your life recovery and restoration. In circumstances of dismissal from the program, Inspiration will help in transitioning out to the best of our ability.

Suboxone Policy: Inspiration only accepts residents who are prescribed to NO MORE THAN 8mg of Suboxone per day. After entrance into the Inspiration Recovery Program, you must FULLY taper off Suboxone before you can complete Phase One, obtain a phone, and engage in work privileges.

Activity Participation: Regardless of your transitional housing need, all residents participate in a variety of activities, programs, and classes to best achieve success in your transitional development. Refusal to participate in your recovery will result in your termination from the Inspiration Recovery Program.

Financial Terms: Inspiration does not expect money from the resident to be accepted into the program. The fee for room and board and services is $210 and begins when the resident begins employment and can take financial responsibility.

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ADDITIONAL NOTES

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I, First Name Last Name , fully understand and agree to all policies described in this application. To the best of my ability, I have provided correct and true information. If anything I have provided is revealed to be false, my application will be denied. I also understand the information I have provided will remain confidential and will only be used to provide team members of Inspiration team members with information that will help in my recovery and/or transition.
Typed Signature * Date *

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Please verify that you are human* This field is required.