Application for Admission to Eden S Glory

Application for Admission to Eden’s Glory

GENERAL:Today’s Date: ______

Name: ______

First MiddleLast

Provide an address where you would reside if you were not in the program: ______

Street CityStateZip

Phone: ( ) ______SS Number ______

Birth Date _____/_____/______Age ______Sex ______Weight ______Height______

Last grade completed ______Diploma: Yes or No GED: Yes or No

Are you an American citizen?YesNo

Do you have a valid driver’s license? YesNo

If yes, Issuing State _____ If no, explain: Expired Suspended Revoked Never Issued

Do you have access to your driver’s license?YesNo

If no, do you have access to any kind of picture ID? YesNo

Do you have access to your birth certificate?YesNo

Do you have access to your social security card?YesNo

Served in any branch of the military? Yes No

Do you have any Reserve or military obligations at this time? YesNo

PERSONAL:

Have you ever had any of the following symptoms?

Memory lapsesYesNo

Spacing OutYes No

Loosing Track of TimeYes No

Headaches/MigrainesYes No

Hallucinations (Auditory or Visual)YesNo

FlashbacksYes No

NightmaresYes No

Suicidal ideationYes No

Homicidal ideationYes No

Have you ever been:

In prostitutionAge started ______How long ______What States: ______

StripperAge started ______How long ______What States: ______

Have you ever had a pimp or a madam? YesNoHow Long ______

Describe the relationship: ______

Any attempts to leave: ______

Reasons unable to leave: ______

Have you ever been a madam or a bottom girl?______For how long? ______

Do you have any children?YesNo

Child’s Name / Birth Date / Age / Other Parent’s Name / Child Support / Custody
Me State Other

What is your sexual preference?

HomosexualBisexualHeterosexualUncertain
DRUG HISTORY:

Have you ever experimented with drugs or alcohol? YesNo

What caused you to experiment with or become involved with drugs? ______

How old were you when you first used drugs or alcohol? ______

Do you consider yourself addicted? YesNo

Explain: ______

______

Longest period clean? ______When? ______

How does your use of drugs or alcohol affect your life (relationships, health, employment, etc.)

______

Have you ever traded sexual services or anything other than money for drugs or alcohol?

Yes NoIf yes, explain: ______

Fill Out this Chart:

Drug Used: / Usage / How Often Used
Age 1st Time / How recently / Once / Sometimes / Regularly / Excessively
Tobacco
Alcohol
Marijuana
Hallucinogens
Cocaine
Barbiturates (downers)
Amphetamines (uppers)
Heroin
Opiates (pain meds)
Inhalants
Other (______)
Other (______)

I depend on drugs (Check which one(s) apply to you):

_____ To cope with life

_____ For pleasure

_____ To escape reality

_____ To be “in” with the crowd

_____ Other ______

Have you ever been arrested? YesNoHow many times? ______

Date / Charges / Convicted (Yes /No) / Sentence / Time Served

What charges are pending? ______

______

When is your court date? ______

Have you ever been on probation? Yes No

Are you on probation now?YesNoHow long? ______Time remaining? ______

How do you report (circle)? In PersonBy mail/phoneNon-report

How often? ______

Name of probation officer: ______Address:______

Phone: ( ) ______Phone: ( ) ______Fax: ( ) ______

Email: ______

Are you on parole? YesNo

How do you report (circle)? In PersonBy mail/phoneNon-report

How often? ______

Name of parole officer:______Address:______

Phone: ( ) ______Fax: ( ) ______

Email: ______

Have you ever been in prison? YesNo

When? ______Where?______

Name of lawyer: ______

Address: ______

Phone: ( ) ______Fax: ( ) ______Email:______

SPIRITUAL:

Do you believe in God? Yes NoUncertain

Have you ever committed your life to God? Yes No Uncertain

Date______Place______

What were the circumstances that led to this? ______

Who is God to you? God is…

______

Have you ever been involved in the occult?YesNo

FINANCIAL STATUS:

Are you receiving: welfare, unemployment compensation, disability payments, workman’s compensation, alimony, or other income? (Circle all that apply)

Explain: ______

______

Do you have any outstanding debts or fines? YesNo

To Whom and How Much?

______

HEALTH STATUS:

Rate your general health: Excellent GoodFairPoor

Do you have any communicable diseases?YesNoExplain: ______

Do you have epilepsy, seizures, diabetes?YesNoExplain: ______

List any medical diagnosis, problems, or handicaps: ______

Would this inhibit your mobility and/or ability to work? If so, how? ______

Are you presently receiving medical care?Yes No Where?______

Are you currently taking any medications?Yes No

If yes, please list:

Name of Medication / Dosage and Frequency: / Reason for Medication: / Prescribing Dr. name & number:

Do you have any physical or mental problems due to drugs/alcohol?YesNo

If yes, please explain: ______

Have you been hospitalized within the past 12 months? YesNo

If yes, explain: ______

List all food or medical allergies: ______

Have you ever had psychiatric (mental health) care?YesNo

Explain:______

Have you ever attempted suicide?YesNo

If yes, explain ______

Was your suicide attempt drug related? YesNo

Do you feel suicidal now? YesNo

Do you feel hopeless?YesNo

Have you ever had an eating disorder? YesNo

Explain:______

Have you ever self-injured (carving, scratching, marking, picking, burning, cutting, biting, bruising)? Yes No

Explain: ______

______

Are you pregnant? Yes No UncertainHow many months? ______

NARRATIVE TO BE COMPLETED BY POTENTIAL RESIDENT:

What do you hope to gain from your time at Eden’s Glory?

______

What are your short-term goals?

______

What are your long-term goals?

______

PRESENTING CONCERNS:

What is the main concern in your life, as you see it? ______

How have you tried to address this concern? ______

In order of priority, what are your greatest needs?

1. ______

2. ______

3. ______

4. ______

5. ______

What are your expectations of people while you are at Eden’s Glory? ______

What do you think is required of you in order to successfully complete a program like Eden’s Glory?

______

THE MIRACLE QUESTION:

What would your ideal life look like? What would you do differently to have that life?

______

FAVORITES:

What is your favorite meal? ______

What is your favorite color? ______

What is your favorite dessert and candy? ______

REFERENCES:

Have you ever been in any other program before coming to Eden’s Glory? Yes or No

Do we have permission to contact the following programs? Yes or No

Program Name and location: / Contact Name and Number: / Dates of admission and discharge: / Reason for leaving: / Religious or
Non-Religious:

Please List 3 References: Name, Relationship, Contact Information.

Friend or Family______
Program or Shelter Supervisor______
Other______

______

Applicant’s SignatureDate

______

Staff Signature Date

By signing above, I agree that the above information is accurate and true and I give permission for the staff at Eden’s Glory to contact my references, previous program staff and medical providers listed for additional information needed pertaining to my time at Eden’s Glory. I understand that only the information that is needed to assess my readiness and treatment plan will be requested and my current location and possible admission to Eden’s Glory will remain confidential. I also give permission for a background check to be run along with possible drug testing prior to admission to Eden’s Glory.

Once we receive this information, we will be contacting you with any additional questions we may have and we will set up a time for an interview. Following the interview, and once we have any additional necessary information, we will be meeting as a staff to make the decision on acceptance.

Due to the fact that we only have room for four women at a time at Eden’s Glory, our space is limited and if we are unable to accept you at this time, we would like to discuss with you the possibility of adding you to our waiting list until the appropriate time. Thank you for your understanding and patience through this process.

12/17/18