Program Application – Renewed Hope Ministries

Renewed Hope Ministries is a voluntary program. For the spiritual, physical, and emotional well-being of all participants, there are rules and restrictions in place. Please see the Resident Handbook for more information.

Personal Information

Name

Address

Phone

Email

Date of Birth

Place of Birth

Social Security Number

Do you have a valid Driver’s License or State ID?

Marital Status

How many children do you have?

Highest Level of Education Attained

Work Experience

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

Yes

No

Are you currently attending a church or religious organization?

Yes

No

Medical Information

Height

Current Weight

Usual Weight

What is the state of your health?

List all major illnesses (past and present):

List all major surgeries:

List any allergies (food, insect stings, medication, etc.):

List any prescription or over-the-counter medications you are currently taking:

Have you ever had a sexually transmitted disease?

Yes

No

Have you ever suffered from depression?

Yes

No

Have you ever been treated for any psychiatric illnesses?

Yes

No

Have you ever considered suicide?

Yes

No

Have you ever attempted suicide?

Yes

No

Alcohol & Drug Use History

Please list any rehabilitation programs you have attended and if you completed them:

At what age was your first drinking/drugging experience?

What is your alcohol and/or drug(s) of choice?

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 use drugs?

What did you drink or use?

Do you use products containing nicotine (i.e. cigarettes, dip, vape, etc.)?

Yes

No

Criminal History

How many times have you been arrested?

Please list from newest to oldest all charges, dates of arrest, and time served:

Have you ever been charged with any sexual crime?

Yes

No

Are there any current charges pending against you?

Yes

No

Are you currently on probation or parole?

Yes

No

Personal Commitment

Please write a paragraph stating why you would like to come to Renewed Hope Ministries and why you think you’ll be successful at overcoming your addiction.

Have you come to this program on your own free will?

Yes

No

Are you court ordered into this program or any program?

Yes

No

I have read and agree to abide by the Renewed Hope Ministries Resident Handbook, which includes a list of approved clothing and personal items, rules and regulations, disciplinary actions, drug screening policies, and our statement of faith.

Yes

No

I, the undersigned, do solemnly swear the above statements are an expression of my own desire to overcome my addiction to drugs and alcohol, that this application was completed voluntarily, and that the statements contained therein are true and complete to the best of my knowledge.