His Place Men S Program Lettersent

*OfficeUseOnly

His Place Men’s Program LetterSent:

1415 2nd Ave, Opelika AL 36801 InterviewDate:

(334)749-2130Office(334)203-1830Fax Accept/Decline:

Thisinformationisconfidential. Itwillnotbeheldagainstyouorusedtojudgeyouinanyway. Pleaseanswerallquestionshonestlyandcompletely, not doing so will result in a declined application. Aftercompletingtheapplication,pleasewritea5pagestoryofyourlifesothatwemayknowhowtobesthelpyou.

Pleasebeawareweareaspirituallybased12monthrecoveryprogram. Wearefaithbased. Yourroomandboardwillbeprovidedforthroughgenerousdonationsfrompeoplewhocareforyou. Wedorequirea$500.00curriculumfeewhichisnon-‐refundabletoprovidefortrainingmaterialsanddrugtestsneededthroughouttheyear. Whileinour careyouwillberesponsibleforanymedicalordentalcareneeded. Ifyouareseriousinyourdesiretogethelp,pleasecallusregularlytoseeifwehaveanopeningavailableforyou.Yourcontactwithuswillkeepyourapplicationvalid. If wedonothear fromyouwewillonlyholdanapplication30days,after thatyouwouldhaveto reapply.

If you are accepted into the program the following documents will be needed before/upon your arrival:

MedicalPhysical includingpapandliverenzymes

BloodworkTests TestResults:

TB: HIV/AIDS: HepatitisA,B,C:

BirthCertificate: SocialSecurityCard: ValidPictureI.D.

Psychological Evaluation:

************************NoPsychopathicDrugsAreAllowedWhileInProgram*****************************

PersonalInformation:

ApplicationDate:

Name: Phone:______

Address: City: State: Zip:

County: DateofBirth: Age:

SocialSecurity: Ethnicity:

Hair: Eyes: Height: Weight:

DriversLicenseNumber: State: Type: Valid?

Education:

HighestGradeCompleted: Graduated/GED: Yes No:

Emergency Contact:

NamePhoneNumberof PersontoContactinanEmergency:

Whatistheirrelationshiptoyou?

MaritalStatus:

Single: Married: Engaged: Divorced: Separated: Widowed: Numberof timesmarried: Yearsmarriedeachtime:

DoesyourWifesupportyourdecisiontogethelp? Wife’sName: Address: City: St: Zip:

NamesofChildrenandAges:

Parents:

NamesofLivingParents: Address: State: Zip:

Father’scontactphone: Mother’sphone:

Father’sE-‐mail: Mother’sE-‐mail:

NamesofDeceasedParents:

Whendidtheydie?

Howdidtheydie?

Siblings:

Namesandagesofsiblingsincludingyourselfintheorderofbirth:

HobbiesInterests:

Medical:

Pleaserequestanyandallmedical/psychologicalinformationfromprevioushealthprovider,physicians,andcounselors andsubmituponarrival.Physical: PsychEvaluation: MedicareNumber: MedicaidNumber: PrimaryHealthInsuranceCarrierNameNumber: Physician’sNamePhoneNumber: Address: City: St: Zip:

Allergies:YesNo:Listofallergies:

CurrentMedicalProblems–Pleasebecompletespecific:

Pleaselistallpastsurgeriesormedicalhospitalizations:

MedicationsCurrentlyTakingPrescribedandNon-‐Prescribed:

Listanyphysicallimitationsyoumayhaveasindicatedbyaphysician:

Haveyoueverbeentocounseling/psychiatrist?YesNoHowlong?

Haveyoueverbeenthevictimofphysicalabuse?YesNoHowlong?

Haveyoueverself-‐mutilated?YesNoIfyes,howhowrecent?

Haveyoueverbeenthevictimofsexualabuse?Yes No Asachild? AsanAdult? Doyouhaveorhaveyouevercontractedasexuallytransmitteddisease?Yes No

WhichSTD? DateContracted: Treatment:

CurrentStatus: SexualPreference:Heterosexual Homosexual Bisexual

Haveyoueverbeeninvolvedinahomosexualrelationship?

Diet:

Areyouonaspecialdiet?Explain:

Doyouhavefoodallergies?

Haveyoueverbeendiagnosedwithaneatingdisorder?Pleaseexplain:

LegalInformation:

ProbationOfficer:Attorney:

Name:Name:

Address:Address:

Phone:Phone:

Fax:Fax:

E-‐Mail:E-‐Mail:

ListALLarrestsandresults:

Listpendingcourtcases,datesandallegations:

Listanyoutstandingwarrantsforyourarrest:

SubstanceAbuse:

ListAllAlcoholDrugsYouUseorHaveUsed:

Drug: HowOften: HowMuch: LastUsed: Drug: HowOften: HowMuch: LastUsed: Drug: HowOften: HowMuch: LastUsed: Drug: HowOften: HowMuch: LastUsed: Drug: HowOften: HowMuch: LastUsed: Drug: HowOften: HowMuch: LastUsed: Whenwasthelasttimeyouuseddrugs? Alcohol? Howoldwereyouwhenyoufirststartedusingdrugs? Alcohol? Doyouusetobacco/smokecigarettes?Yes No Whendidyousmokelast? PleasenoteHis Placeisasmokefreefacility. Areyouwillingtoquit?Yes No Haveyoueverbeeninanalcohol,drug,ordetoxificationprogrambefore?Yes No

Pleaselistthefacilities:

Wasitareligiousornon-‐religiousprogram?

Explainhowithelpedorhinderedyourrecovery?

Howinvolvedwereyourfamilyinyourrecoveryprocess?

Howwillingaretheyinbeinginvolvedinitnow?

Spiritual:

Whatlifecontrollingproblemsdoyouseeinyourlifethatyouneedorwanttoresolve?

DoyoufeelthatyouhaveaneedforGod?

HaveyouevercommittedyourlifetoGod?

WhatisyourpresentrelationshipwithGodlike?

DoyoureadtheBible?

AreyouopentoBiblicalsolutionstoyourproblems?

Areyouamemberofanychurchorspecificreligion?

TypeofReligion:Denomination:

Financial:

Explaincurrentfinancialobligations:

Amountofcurrentincomeandsources:

Pleaseexplainwhyweshouldtakeyouintoourrecoveryprogram:

Whatwouldyouliketoseehappeninyourlifewhileyouarewithus?

Areyoureadyforyourlifetobechanged?

Howwillingareyoutodowhateverittakestomakethechange?

Ifyouwanttotellusmoreaboutyourself,pleasefeelfreetosharewithusanythingyoumayfindimportantforustoknowinorderforustobetterunderstandyourcircumstances:

Applicant’sSignature:Date:

His PlaceDirector:Date: