Program Form – Renewed Hope of Murphy

Program Application

Renewed Hope Ministries is a Christian, faith-based residential recovery ministry for men seeking freedom from alcohol and drug addiction. The program emphasizes a relationship with Jesus Christ, personal responsibility, accountability, work, fellowship, and a structured recovery environment.
Renewed Hope is not a hospital, medical detoxification facility, or emergency psychiatric facility. Applicants must be appropriate for a non-medical residential setting. Completion of this application does not guarantee admission.
Please answer every question honestly and completely. Information is used to help determine whether Renewed Hope can safely and appropriately meet your needs.

1. PERSONAL & CONTACT INFORMATION

Every entry is a required field. If the field does not apply to you, Type N/A. The form will not be sent unless all fields are filled in.

Full Legal Name (First / Middle / Last / Suffix)

Preferred Name / Nickname

Date of Birth

Primary Phone

Current Street Address

Apt/Suite

City

State

ZipCode

# of Children

Valid ID Type / State / ID Number

Do you currently have a valid driver's license?

Yes No

Emergency Contact Name and Relationship

Emergency Contact Phone

Emergency Contact Address

2. SUBSTANCE USE & WITHDRAWAL HISTORY

Other, if not listed

Substance of choice / main problem

Age of first alcohol/drug use

Date and approximate time of last alcohol/drug use

What did you use, how much, and by what route?

Has your alcohol/drug use recently

Increased Decreased Stayed about the same

Longest period of sobriety in the past 2 years

Have you ever experienced serious withdrawal symptoms?

Yes No

Have you ever had a withdrawal seizure, delirium tremens (DTs), hallucinations, or required medical detox?

Yes No

If yes to withdrawals, explain and what happened and when:

Are you experiencing withdrawal symptoms right now

Yes No

If yes, describe current symptons

Have you ever overdosed or required naloxone/Narcan?

Yes No

If yes, explain and give approximate date(s)

3. PREVIOUS TREATMENT & RECOVERY

Have you previously attended detox, residential treatment, rehabilitation, sober living, or another recovery program?

Yes No

If yes, list the most recent program(s) below.

Program/Facility

Approximate Date(s)

Completed

Yes No

Reason for Leaning/Outcome

Program/Facility

Approximate Date(s)

Completed

Yes No

Reason for Leaning/Outcome

Program/Facility

Approximate Date(s)

Completed

Yes No

Reason for Leaning/Outcome

Program/Facility

Approximate Date(s)

Completed

Yes No

Reason for Leaning/Outcome

What has helped you stay sober in the past?

What usually leads you back to drinking or using?

4. MEDICAL INFORMATION

How would you describe your current health?

Excellent Good Fair Poor

Weight lbs.

Height ft/in

List current medical conditions or significant health problems:

List significant surgeries, injuries, or hospitalizations that may affect your participation:

Do you have any condition that limits walking, lifting, standing, working, or normal daily activities?

Yes No

If yes, describe the limitation:

List all prescription and over-the-counter medications you currently take (name, dose, reason):

List medication, food, or other serious allergies and the reaction:

Health insurance provider (if any)

Primary care provider/clinic and phone (if known)

5. MENTAL HEALTH & SAFETY

Have you ever been diagnosed with or treated for a mental-health condition?

Yes No

If yes, list diagnosis, treatment, and approximate dates

Have you ever been hospitalized for a mental-health crisis?

Yes No

If yes, explain and give approximate date(s):

Have you ever intentionally harmed yourself or attempted suicide?

Yes No

If yes, briefly explain and give approximate date(s):

During the past 30 days, have you had thoughts of killing yourself or seriously harming yourself?

Yes No

Are you having thoughts right now of killing yourself or seriously harming yourself?

Yes No

IMPORTANT: A 'Yes' answer does not automatically disqualify an applicant. Current or recent safety concerns require staff review and may require evaluation by an appropriate medical or mental-health professional before admission.

6. LEGAL INFORMATION

Number of times arrested (approximate)

List significant criminal charges/convictions that may affect placement, safety, court obligations, or program participation:

Are any criminal charges currently pending?

Yes No

Upcoming court date(s), location(s), and charge(s)

Do you have any outstanding warrants that you know of?

Yes No

Are you currently on probation, parole, pretrial supervision, or another form of court supervision?

Yes No

Officer / supervisor name and phone

Have you ever been charged with or convicted of a sexual offense?

Yes No

If yes, please explain

Are you being ordered or required by a court, probation/parole officer, employer, or another person to enter this program?

Yes No

If yes, please explain

7. EDUCATION, EMPLOYMENT & PRACTICAL INFORMATION

School/Training/Trade

Are you currently employed

Yes No

Current or most recent employer / occupation

Approximate dates employed

Briefly describe your work experience and skills:

Military Service

Yes No

Branch

Discharge type

List any court, family, employment, transportation, medical, or other obligations that could interfere with full participation in the program:

8. FAMILY & SUPPORT

Who are the most important supportive people in your life?

Do you have child-support, alimony, or other ongoing family financial obligations?

Yes No

If Yes, describe:

Person who should be contacted regarding important family matters (if different from emergency contact)

9. CHRISTIAN FAITH & SPIRITUAL BACKGROUND

Renewed Hope Ministries is intentionally Christian. Residents are expected to participate in the spiritual components of the program, including Christian teaching, Bible study, prayer, church services, and other scheduled program activities.

Are you willing to participate in the Christian spiritual components of the program?

Yes No

Do you currently attend a church or Christian fellowship?

Yes No

Church / fellowship name
(if applicable)

Do you currently read the Bible?

Yes No Do not pray

Describe your current relationship with God, if any

What would you like to learn or strengthen spiritually while at Renewed Hope?

10. MOTIVATION & READINESS FOR RECOVERY

Are you applying to Renewed Hope
of your own free will?

Yes No

Have you personally decided that you
want to stop using alcohol and/or drugs?

Yes No

Why are you seeking help now?

In your own words, describe why you want to come to Renewed Hope Ministries?

What are you willing to change in your life in order to remain sober?

What do you hope your life will look like one year from now?

11. PROGRAM & FINANCIAL ACKNOWLEDGEMENT

Program contribution: I understand that the current program contribution is $300 per month for the first six months. After six months, the contribution is $500 per month, and residents may become eligible to work at that stage, subject to program requirements and staff approval.

I understand the program contribution described above.

Yes No

I understand that Renewed Hope is a voluntary Christian recovery ministry and is not a hospital, medical detoxification facility, or emergency psychiatric facility

Yes NO

I understand that admission and continued participation
require compliance with program rules, schedules,
drug/alcohol testing, and staff direction.

Yes NO

I understand that additional admission documents, financial terms, releases, policies, and the resident handbook may require separate review and signature.

Yes NO

12. APPLICANT CERTIFICATION

I certify that the information I have provided in this application is true and complete to the best of my knowledge. I understand that false or intentionally omitted information may affect admission or continued participation. I authorize Renewed Hope Ministries staff to contact me regarding this application and to discuss information needed to determine whether the program is an appropriate placement for me, subject to any separate authorization required by law.

Applicant Signature(A simulated signature font will be used)

Print your name

Date Submitted