Saving Grace Ministries

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APPLICATION FOR ACCEPTANCE TO SAVING GRACE MINISTRIES

(6 month program)

This information is confidential and information in this application will not be held against you or used to judge you in any way. Saving Grace Ministries is dedicated to helping those who need emotional and spiritual healing and restoration. If for any reason Saving Grace Ministries cannot meet your particular need, we may be able to refer you to someone who can. Please answer all questions honestly so we may know how best to help you. Please do not leave any blanks in your application as this will delay the processing.

Name:______________________________ Date:____________ Name you go by:___________

Present Address:________________________________________________________________

City:________________________________ State:_______________ Zip:______________

Cell Phone #: ( )____________________________ Email:______________________________

Telephone # Home: ( )______________________ Work: ______________________________

Contact Name: _________________________________________________________________

Address:_______________________________________________________________________

City:________________________ State:________________ Zip:_______________

Telephone # Home: ( )__________________________ Work: ( )________________________

Referred by: Court:________ Parents:_________ Church:_________ Other(specify):__________

Telephone # ( )_________________________________

Information about You

Date of Birth:____________________ Age:______________ Race:__________________

City and state of Birthplace:__________________________________________________

Drivers License Number (and expiration date):___________________________________

Physical Characteristics: Height:______ Weight:_____ Eye Color:_______ Hair Color:____

*Please be sure to bring a photo ID and Social Security card with you*

Marital Status:

Single: __________ Married: __________ Divorced: ___________ Widowed: ___________

Husbands Name (if married): __________________________________________________

Children

Do you have any children? _____________ How may? ___________________

List names and ages:

1 - __________________________________ Age: ______________

2 - __________________________________ Age: ______________

3 - __________________________________ Age: ______________

Who has custody of you children? ___________________________________

What arrangements are being made for your children while you are at Saving Grace

Ministries? ___________________________________________________________

Are you on any type of government or financial assistance? ____________________

Medical

Medications allowed Tylenol, blood pressure meds, diabetic meds.

Do you have any allergies? ___________ List: _______________________________

_____________________________________________________________________

List any and all medications that you take:

Medication Dosage Reason For How Long

____________ _________ _______________________ _________________

____________ _________ _______________________ _________________

____________ _________ _______________________ _________________

Do you have, or ever had, a problem with food or eating? ____________________________

Explain: ____________________________________________________________________

Have you ever been diagnosed with an eating disorder or treated by a physician for one? ___

Explain: _____________________________________________________________________

Doctors name & phone number: _________________________________________________

List any medical conditions (asthma, migraines, thyroid, diabetes, blood pressure, heart problems, etc.) that you may have as indicated by a physician: _________________________

____________________________________________________________________________

Would the finances for your personal needs while at Saving Grace Ministries be sponsored by a

church, ministry, family, or individual, if so whom? ____________________________________

Medical

Saving Grace Ministries provides food and shelter, but we are not responsible for medical expenses, prescriptions, or doctor visits. It is your responsibility or your sponsoring agency to cover these expenses. Arrangements should be made prior to residency. If none is available to you please inform the Director during your interview.

If you have blood sugar problems then you need to bring your monitor with you so you can keep it checked.

Substance Abuse

Have you ever experimented with the following substances? (circle)

Alcohol Crank Amphetamines (uppers)

Cocaine Opium Barbiturates (downers)

Heroin Crack Inhalants (Glue, Paint Thinner, etc.)

Marijuana Ecstasy Methamphetamines

Morphine Crystal Meth Other: ___________________________

Drug of choice:

1 - _____________________________ Length of Use: ____________________________

2 - _____________________________ Length of Use: ____________________________

3 - _____________________________ Length of Use: ____________________________

4 - _____________________________ Length of Use: ____________________________

Habit cost per day? ______________________ Longest period clean? _______________

Have you ever been in an alcohol, drug, or detoxification program before? ___________

(please list facilities below)

Was it religious or non-religious? _____________________________________________

Date of Entry Program Name City/State Reason for Leaving Date of Discharge

___________ _____________ ________ _______________ _______________

___________ _____________ ________ _______________ _______________

___________ _____________ ________ _______________ _______________

Counseling

Have you ever been diagnosed or treated for (please mark yes or no):

DID/Dissociative Disorder ________ ADD _______ ADHD _______ Schizophrenia __________

Bi-Polar Disorder __________ Borderline Personality Disorder __________

Have you ever been to counseling? ___________ (Please list facilities/persons below)

Have you ever received psychiatric care or been in a psychiatric hospital? ________________

(Please list facilities……)

Date of Entry Program Name City/State Reason for Leaving Date of Discharge

___________ _____________ ________ ________________ _______________

___________ _____________ ________ ________________ _______________

___________ _____________ ________ ________________ _______________

Please sign release forms with the above facilities/programs/counselors and have your records forwarded to Saving Grace Ministries.

Have you ever been a victim of rape ________ or incest _________? How old were you? _____

Have you ever been the victim of sexual abuse _____ physical abuse _____or ritual abuse ____?

Have you ever been involved in prostitution? Yes ________ No ________

Lesbianism? Yes _______ No ________

Have you ever tried to commit suicide? ____________ When? _________

Why? _________________________________________________________________________

Have you ever self-mutilated? Yes ________ No ________ How? _________________________

Legal Background

(We will not fax lawyers, social service, or courts unless you are living at our facility)

Have you ever been arrested? __________ How many times? __________ Dates, Charges, etc.

______________________________________________________________________________

Do you have any pending court dates? ______________

Explain: _______________________________________________________________________

Are you currently incarcerated? _______ How long? _______ Length of Time Remaining? _____

Name of Attorney of Legal Representative: ___________________________________________

Telephone # ______________________________________

Have you ever been on probation or parole? ________ Are you now? ___________

How long? ___________ Length of time remaining? __________________________

How often do you report? ______________ In person or through mail? __________

Name of probation or parole officer: ______________________________________

Address: ____________________________________________________________

Telephone Number: ( ) ___________________________________

(All court dates must be taken care of before you come or rescheduled until after you graduate from our 6 month program.)

Release of Information

All matters relating to applicant records and info are considered confidential and treated as such by staff of Saving Grace Ministries. Information regarding such matters cannot be given without written consent of the resident and/or parent or guardian.

Name of Applicant: ______________________________________

Date: __________________

I ______________________________ do herby give permission to Saving Grace Ministries to share information related to my application to the program with:

1 - ____________________________________________________

2 - ____________________________________________________

3 - ____________________________________________________

I also give the following person(s) and/or facility permission to exchange the following information with Saving Grace Ministries for the purpose of my application to the program.

1 - ____________________________________________________

2 - ____________________________________________________

3 - ____________________________________________________

Medical Records & Info. ______ Personal History Info. _____

Education Info. & Records _____ Discharge/Treatment Records ____

Psychiatric Info. & Records _____

Pre-Admission Blood Test Report

This form is to be submitted to your healthcare provider (doctor, clinic, or Health Department), and then faxed directly to Saving Grace Ministries by them.

______________________________ applied for entrance into Saving Grace Ministries for a 6 month drug and alcohol renewal program.

Instructions: Please complete in full, then fax directly, with your agency’s cover sheet, to Saving Grace Ministries, at 910-447-1099 or mail to:

Saving Grace Ministries

P.O. Box 424

Rose Hill, NC 28458

Thank you,

Tonya Taylor, Director

910-447-1099

Results and Recommendations

HIV Test –

STD Test –

TB Skin Test –

Pregnancy Test -

Hepatitis C –