Please provide First and Last name, Address, and Phone Number
Please provide First and Last name, Address, and Phone Number
Please provide First and Last name, Address, and Phone Number
First and Last Name, Address, Phone Number
Include Charge, Date, County, and Court date
We do not act as your attorney. If you are in jail, you will need your attorney to do the legal work for you. We are unable to provide transportation from jail. Your attorney may contact the Program Director, Kathy Bryant for further information.
All legal matters concerning custody of minor children or change in Power of Attorney must be handled prior to acceptance.
Medicare, Medicaid, BCBS, etc
Medication/MG Prescribed/Dose/RxDate/Quantity/Physician/Reason
the above information is true and that all medications are prescribed for the labeled purposes only and are currently the only medications I am using. No exceptions will be made allowing the use of narcotic prescriptions while enrolled in the program.
this program is a Christian based organization. I am willing to commit to 12-18 months inpatient treatment. I am willing and able to sleep on a mattress on the floor, bunk bed, or cot. I understand that I will participate in the work therapy program, in return for my recovery. I f you are not able to physically and mentally participate in work therapy this program is not for you.
The $525.00 intake fee is due up. This fee is one time and is non-refundable.
You will receive a letter of acceptance or denial by mail. If this form is not filled out completely, your name will not be added to the waiting list.
All forms must be filled out completely or your application will not be considered. Our program is not a detox facility. If you arrive at this facility and realize you need detox, we will not be able to hold your bed for you. However, at the time of detox completion, a release form from the physician must be turned in and a place will be made available for you at the facility.
