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Haven Golf Classic

Women's Program Application

Application

Full Name

Date

Age

Address

City

State

Zip Code

Phone Number

Email

Emergency Contact

Phone Number

Relationship

Marital Status

Religious Background

Church Name

Are you a Member?

Yes

No

What are you struggling with?

Drugs

Prescription Meds

Alcohol

Sex/Pornography

Gambling

Nicotine

Emotional

Anger

Spiritual

Marriage

Other

Substance Abuse History

Alcohol

Amphetamine

Barbiturates

Caffeine

Cocaine

Codeine

Crack

Demerol

Ecstasy

Hashish

Heroin

Hydrocodone

Klonopin

LSD (acid)

Marijuana

Methamphetamine

Nicotine

New Option

Opium

Oxycodone

Ritalin

Xanax

Other

What is you addiction at this time?

How long have you been using?

When was the last time you used?

Do you smoke?

Yes

No

Are you willing to quit

Yes

No

Do you understand that we are a smoke free facility and that you will not be allowed to smoke while in the program?

Yes

No

Health History

Accidents

Allergies

Blackouts

Cancer

Convulsions

Diabetes

DT's

Epilepsy

Hallucinations

Handicaps

Hearing Voices

Heart

Hepatitis

High Blood Pressure

HIV

Injuries

Liver Disease

Physical Limitations

Seizures

Shakes

Sleeping Disorder

Suicide Attempts

TB

Ulcers

Other

Do you have food allergies

Yes

No

If so, explain

What other medical problems do you have?

Are you able to climb stairs, exercise, and do cleaning chores?

Yes

No

Do you have any Psychiatric Disorders?

Yes

No

If so, diagnoses

Have you ever been hospitalized for mental or emotional disorders?

Yes

No

If so, Where & When?

Your Doctor's name

Doctor's phone number

Name of medication

mg

Prescribed by

Times taken daily

Have you been in treatment before for substance abuse or alcohol

Yes

No

If yes, where?

Dates

Did you finish the program?

Yes

No

If no, reason for leaving?

Contact Person

Phone Number

May we contact them?

Yes

No

Do you have any pending legal obligations?

Yes

No

Do you have any hearings?

Yes

No

Have you ever been arrested

Yes

No

If so, how many times

Last date

Charges

Are you on probation?

Yes

No

If so, probation officer's name?

Probation officer's phone number

What are the charges?

Are you court ordered to a program?

Yes

No

May we contact your Probation Officer?

Yes

No

I UNDERSTAND THAT I AM ENTERING A LONG-TERM, RESIDENTIAL PROGRAM CONSISTING OF 2 PHASES. PHASE 1 IS A MINIMUM OF 6 MONTHS, PHASE 2 IS A MINIMUM OF 6 MONTHS; THE WHOLE PROGRAM IS 12 MONTHS TOTAL. I AM COMMITTED TO SUCCESSFULLY COMPLETING THE PROGRAM.

Yes

I UNDERSTAND THAT I AM SUBMITTING MYSELF TO THE SPIRITUAL GUIDANCE AND AUTHORITY OF THE WOMEN’S MINISTRY STAFF

Y

I UNDERSTAND THAT I WILL BE REQUIRED TO HAVE PREGNANCY, HEP C, HIV AND TB TESTS BEFORE ENTERING THE WOMEN’S MINISTRY PROGRAM. (YOU CAN GET THESE AT YOUR LOCAL HEALTH DEPT. OR FAMILY DOCTOR)

Yes

I UNDERSTAND THAT I WILL BE REQUIRED TO SUBMIT A CRIMINAL BACKGROUND REPORT BEFORE ENTERING THE WOMEN’S MINISTRY PROGRAM.

Yes

I UNDERSTAND THAT IF THE WOMEN’S MINISTRY STAFF IS MADE AWARE OF ANY OUTSTANDING WARRANTS ON ME THEY HAVE NO CHOICE (BY LAW) BUT TO REPORT IT

Yes

I UNDERSTAND THAT THE WOMEN’S MINISTRY IS NOT A MEDICAL FACILITY AND THERE ARE ONLY CERTAIN MEDICATIONS THAT I WILL BE ABLE TO TAKE THERE

Yes

I UNDERSTAND THAT THE WOMEN’S MINISTRY IS A CHRISTIAN PROGRAM AND NOT AN AA OR NA PROGRAM

Yes

I UNDERSTAND THAT I WILL NOT BE ALLOWED TO SMOKE OR USE TOBACCO AT ANY TIME WHILE ENROLLED IN THE WOMEN’S MINISTRY PROGRAM

Yes

I UNDERSTAND THAT A $100.00 DONATION IS REQUESTED UPON ENTRANCE

Yes

Thank you for applying for the Haven of Rest's Women's Ministry Program.

We will get back to you as soon as possible.

Oops, there was an error sending your application.

Please try again later.

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