Application for Admission

APPLICATION FORM FOR RENEWED HOPE MINISTRIES

PLEASE PRINT AND FILL OUT

MISSION STATEMENT:  Renewed Hope Ministries is a 12 month residential Christ-centered, discipleship-based program to help men struggling with drug and alcohol addiction.   Renewed Hope Ministries (RHM) provides recovery through Biblically based counseling services and a compassionate staff who will support them in a program based on Biblical principles.

IMPORTANT

THE RHM TREATMENT PROGRAM IS A “VOLUNTARY PROGRAM”. For the spiritual, physical, and emotional wellbeing of the participants, there will be restrictions in place as part of the program at RHM. There is one real requirement for admission-that a person have a desperate desire to overcome their problem with drugs and alcohol.

We have found that the only person we can help overcome their problems are those who come of their own free will, and those who have made a decision to do it for themselves and not for their wives, mother, father, girlfriends, etc.

If a person doesn’t want to be here, they will not allow us to help them.

Personal Information:

Name________________________________________________________      

         (Last, First, Middle)

Phone_____________________________________

Address__________________________________________________________
              (PO Box or Street #) (City) (State) (Zip)

Date of Birth__________Age______                                                               
Place of Birth_____________________SS#____________________________              
List any valid form of identification (Driver’s License, State ID, etc.): Type_____________State__________Number__________________________

Emergency Contact________________________________________________
                                (Name, relationship, phone #)

Address__________________________________________________________
             (PO Box or Street #) (City) (State) (Zip)

Parents Names (if Iiving)_____________________________________________

Parent’s Address___________________________________________________
                            (PO Box or Street #) (City) (State) (Zip)  

Are Parents Separated/Divorced?_______Is either parent deceased?______  How many brothers do you have?________________Sisters?_______________

Marital Status/Children:

Married_____Single_____Separated_____Divorced_____Widowed______

List reasons for divorce or separation___________________________________

Wife’s Name_____________________________  Date of Birth____________    
Phone #_______________________

Wife’s Address___________________________________________________    
                        (PO Box or Street #) (City) (State) (Zip)

How many children do you have?_____   Where are they?__________________________                                                  
Are you subject to any alimony/child support payments?_______If so how much?__________________

Education:

Did you graduate from High School?_____ Year?___________
Did you attend college?______ Year?___________
What was your major?___________Degree Earned?_____
Did you attend trade school?_____What trade?_____________
Did you complete?______

Work History:

Usual Occupation__________________________________________________                                           
How many years experience?______

List last three employers:
________________________________________________________________
Name of company     City, State & Phone #
________________________________________________________________
Position    Start Date     End Date
________________________________________________________________
Name of company     City, State & Phone #
________________________________________________________________
Position    Start Date     End Date
 ________________________________________________________________
Name of company     City, State & Phone #
________________________________________________________________
Position    Start Date     End Date

Are you currently working?_____If not, why?____________________________

Number of jobs in the last 5 years?______ Preferred type of work?___________
________________________________________________________________

Military Experience:

Are you a veteran?_____Branch of service______________
Highest Rank____________
How long were you in the service?_________
Date and type of discharge_____________

If discharge was not honorable, please explain___________________________
________________________________________________________________

Were you ever court-martialed?______ If so, please explain________________
________________________________________________________________

Medical Information:

What is the state of your health?
____Excellent____Good____Fair____Poor____Declining Height
Weight________Usual Weight_______ Any recent weight changes?_____________                                                                      
List all major illnesses and/or surgeries that you have or have had  ________________________________________________________________

Have you ever had a sexually transmitted disease?________
What?______________When?___________
When were you last tested for HIV_________ Hepatitis C______TB__________ RPR__________

Do you smoke or chew any form of tobacco (i.e. cigarettes, dip, etc.)?_________
Are you currently taking any prescription or over the counter medication? ______
If yes, what?______________________________________________________
How long have you been taking it?_______________

Please list any side effects associated with this medication_______________________________________________________

Have you ever suffered from depression?_____   If yes, please describe

________________________________________________________________

Have you ever been treated for any psychiatric illness?_______
If yes, please describe condition and treatment______________________________________

Have you ever considered commiting suicide?_____When?_________________                                        
Have you ever attempted suicide?______When?______
Why?____________________________________________________________

Note: RENEWED HOPE MINISTRIES IS NOT A MEDICAL FACILITY AND CANNOT GIVE MEDICAL CARE. WE NEED TO KNOW WHO WILL BE RESPONSIBLE FOR MEDICAL EXPENSES INCURRED WHILE YOU ARE HERE.

Insurance Company _________________________________________________ Address___________________________________________________________

Policy Number______________________________________________________

If you have no insurance, give the name of person who will be responsible for medical expenses incurred while you are at RHM or if you yourself will be responsible.

Name_________________________ Relationship: ________________________ Address__________________________ City___________________ State__________ Zip Code_______________ Telephone: _________________________

If the applicant is currently taking prescribed medication for medical purposes, and it is agreed to be medically prudent by a qualified practioner, then the student at RENEWED HOPE MINISTRIES is responsible for arranging with their medical practioner a medically supervised controlled substance reduction plan with the goal of becoming chemically free by the end of their program at RENEWED HOPE MINISTRIES.

AGREED TO BY APPLICANT___________________________DATE__________________

Alcohol/Drug Use History:

Please list any rehabilitation centers you have attended:
Name_________________________________________ When?__________
Completed? Yes or No
Name_________________________________________ When?__________
Completed? Yes or No
Name_________________________________________ When?__________
Completed? Yes or No
Name_________________________________________ When?__________
Completed? Yes or No

What is your drug(s) of choice?_______________________________________                     
At what age was your first drinking/drugging experience?___________________                                                     
How much has your drinking/drugging pattern changed lately?_____________________
________________________________________________________________

What is your longest period of sobriety in the past two years?________________

When did you last drink or get high?____________________________________
What did you drink/use?_____________________________________________

Is there any other information about your drug or alcohol use that we need to know? ______________________________________________________________________
______________________________________________________________________

 

Criminal History:


Number of times arrested?___________________________________________

Please list from newest to oldest all charges, date of arrest, and time served for each:
Charge_______________________________   Date of arrest________         Time served__________
Charge_______________________________   Date of arrest________         Time served__________
Charge_______________________________   Date of arrest________         Time served__________

Have you ever been charged with any sexual crime?______________________
Are there any current charges pending against you at this time?____________ Pending Court Dates?__________   
Are you currently on probation/parole?___________   If so, for how long?__________________                                      
Name of Parole Officer:_____________________________________________
Phone #________________________________

Spiritual Background:

Have you ever attended a church or belonged to a religious organization?

Yes ______ No _____ If yes, list name ___________________________ 

Are you currently a member of a church congregationor religious organization?

Yes ______ No _____ If yes, list name ___________________________ 

Have you ever had a personal relationship with God?  What does that mean to you?

______________________________________________________________________________

______________________________________________________________________________

Are you willing to receive spiritual teachings based on Christian principles?

Yes _____ No _____

______________________________

What is your church affiliation?

________________________________________             
Do you read the Bible?_________  If so, how often? _________________________

Do you pray?_________  If so, how often? _______________________                                                                 
Are you saved? ________________ If so, when? _________________________

Briefly describe your testimony and your walk with Christ since that time.
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________

Please write a paragraph stating why you would like to come to Renewed Hope Ministries at this time in your life.
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________

Personal References:

Please provide 3 personal character references (at least one from a pastor or church staff member):

Name:_________________________________  Relationship:_______________                            
Phone #:_______________________________

Name:_________________________________  Relationship:_______________                            
Phone #:_______________________________

Name:_________________________________  Relationship:_______________                            
Phone #:_______________________________

RENEWED HOPE MINISTRIES FINANCIAL AGREEMENT

RHM is a voluntary drug and alcohol treatment facility.  We do not accept court ordered applicants, feeling that our program is appropriate only for men who are sincerely, even desperately, seeking sobriety.  If an applicant’s primary motivation is to impress someone, family pressure, probation, parole or for any other reason, it is unlikely that this program will be right for them.

A list of current medications with an adequate supply or a prescription and means to purchase them is required.

A $150.00 medical deposit is due upon entering RHM, which is used to defray any medical needs during the stay.  There will be no refund if the student fails or refuses a drug test or leaves early. 

Room must be in satisfactory condition before departure for a refund to be given, also, if at least half of tuition ($1800.00) is not paid upon departure there will be no refund.

The total cost for the year program is $3600.00.  A minimum of $500.00 down is required and the balance can be made in 5 installments of $620.00.

If the total cost is paid up front ($3600.00) and a student withdraws, or is discharged from RHM program within the first 5 weeks (35 days) of their stay, ½ of their money will be refunded to the person or persons who paid the initial fees.  If a student withdraws, or is discharged from the program after the 35-day period there will be no refund.

The student or the family of the student is required to make payments on the balance of the tuition.  We are willing to work with you or your family on payment arrangements.  We need an address where the bill is to be sent.

Personal Commitment

Have you come on your own free will? Yes _____ No _____

Are you court ordered into this program, or any program? Yes _____ No _____

If you are found to be court ordered, you will be dismissed from the program IMMEDIATELY, and the court notified.  Do you agree with this? Yes _____ No_____

Have you made a decision to overcome your problem? Yes ______ No______

In your own words tell about your desire to overcome your problem.

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

________________________________________________________________________

I, the undersigned do solemnly swear the above statement is an expression of my own desire to overcome my problems with drugs and alcohol, and that it is done voluntarily, and that the statements contained therein are true.

Signed__________________________________________Date____________________

Wittness__________________________________________Date___________________

Staff determination:  Is there a desperate desire? Yes _________ No ________

Staff Signature______________________________________Date__________________

You may fax or email this completed application to:  (828) 837- 4648 or This email address is being protected from spambots. You need JavaScript enabled to view it.

Someone will contact you shortly.   

Thank you for your interest in Renewed Hope Ministries.