Recovery Program Application

Name

First

Last

Date of Birth

The Union Mission Addiction Recovery Program is faith-based and operates in two phases designed to last 12 to 15 months. The first phase focuses on recovery education, biblical life skills, counseling and therapy services. Clients work with the Union Mission Behavioral Health Center.
We focus on helping our clients get spiritually, mentally, and physically healthy. The second phase focuses on reintegrating into society. Clients get a job and learn financial accountability and budgeting.

We frequently work with the court system to provide progress updates and/or drug screen results as requested. Our program is free to participants.

Eligibility requirements:
- We have a preschool onsite and are unable to house registered sex offenders.
- We are unable to house women who are pregnant.
- We are not certified to accept parole home plans.
- We do not offer Medically Assisted Treatment, i.e. buprenorphine and its derivatives.
- Clients must be physically able to climb stairs.

Once you complete and submit this application, the program coordinator
will contact you. Completing this application does not guarantee acceptance.

Best way to contact you?

Current location

Phone

Can we leave a message?

Yes

No

When can you arrive to our program:

Explanation

Who referred you to the program?

Do you have any history with any of the following? Check all that apply:

Drug of Choice?

How long have you used?

When was the last time you used?

What did you use?

Have you been through detox?

Yes

No

Have you ever been in a recovery program?

Yes

No

When?

Where?

Graduate?

Yes

No

Have you been a client at Union Mission before?

Yes

No

When?

Why did you leave?

Do you know anyone who is currently residing at Union Mission?

Yes

No

What is your relationship to them?

Do you have any physical health problems? Explain:

What medications are you taking? List them all:

How will you be paying for your medical needs?

Are you currently receiving disability?

Do you have physical limitations?

Yes

No

Explain:

Are you able to walk up and down 3 flights of stairs and perform community service?

Yes

No

Have you been diagnosed with a mental health condition?

Yes

No

What was your diagnosis?

Were medications given?

Yes

No

What were the medications?

Were you hospitalized?

Yes

No

Where?

Over the course of your life, how many times have you been hospitalized?

Have you ever attempted suicide?

Yes

No

When?

Have you ever been arrested?

Yes

No

How many times?

Are you incarcerated at this time?

Yes

No

What facility?

How much time have you spent incarcerated?

What were the charges?

Currently on probation/parole/home confinement?

Yes

No

Upcoming court hearings?

Yes

No

Do you have any out of state charges?

Yes

No

Attorney

Probation/Parole Officer

Do you have any violent criminal offenses?

Yes

No

Please explain:

Restraining Orders, DVPs, or No Contact Orders?

Yes

No

Marital Status

Single

Married

Divorced

Children Information (Name/Age/Sex/Custody)

Where is your spouse?

What is the status of your relationship?

Do you pay child support?

Yes

No

Do you have an open CPS case?

Yes

No

Who will care for your child if you attend the program?

Do you have the following:

If accepted, bring the original documents with you when you come.

I understand the following about living at Union Mission Ministries Addiction Recovery Program: