ABUNDANT HOPE MINISTRY

1808 Buffalo Trail Morristown, TN 37814
Phone:  423-254-1700 | Fax: 423-254-1701

Entry Assessment Form

We are a faith-based recovery program with 3 phases. In the 90-day immersive phase, participants undergo personalized assessments, counseling, community activities, daily spiritual foundations, celebrate recovery, and church services. Our 6-month Transition Phase is a bridge to real-world reintegration, emphasis is placed on fostering a sense of community engagement, finding employment or continued education, involvement in local churches and volunteer opportunities. Finally, in the 3-month Outpatient Phase, participants are ready for life with ongoing spiritual guidance, counseling, and peer support, ensuring sustained growth and resilience.
2 Corinthians 5:17 says “Therefore if anyone is in Christ, he is a new creation; the old is gone and the new has come.”

Please be informed that to be accepted into Abundant Hope, the Entry Assessment Form must be completed by the individual applying to the program.  After receiving your application, we will review it and send a letter of acceptance or denial back to you.  After receiving a letter of acceptance, you will be required to call or write us every week. If we do not hear from you, your name will be removed from the waiting list.

Section 1: Personal Information

Date: Date
Name: Client first nameClient last name 
Phone: Client phone Email: Client email
Last known Address: Client Address
Date of Birth:Client birthdate Gender:Client gender
SSN:SSN Race: Dropdown
D/L Number:Text field State Issued: Text field

Please List an emergency contact:
Name: Text field Phone: Text field

Section 2: Referral Information

Who referred you to AHM?Client Referred ByReferral Contact Info:Text field

Section 3: Drug History

What is your drug of choice: Client substances of choice
Do you consider yourself an addict: Radio buttons 
Explain:
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Section 4: Medical & Mental Health Information

Current medical conditions: Client health problems 

Do you have any physical or mental disabilities that we should be aware of in order to best support you during the program? Radio buttons

If yes, please explain: Paragraph
Do you currently receive any form of disability income, such as SSI or SSDI? Radio buttons
Medications (include dosage): List all: 
Paragraph
Mental health medications? List all: 
Paragraph
(Note: Certain medications may not be allowed on campus.)
Ever attempted suicide? Radio buttons

Section 5: Legal Information

Pending charges or court dates? Radio buttons 
If yes, explain:
Paragraph
Required to register as a sex offender? Radio buttons
Attorney Name: Text field  Phone: Text field
Probation Officer: Text field Phone: Text field
Probation
TOMIS number Client Number

Section 6: Spiritual Background

Have you accepted Jesus Christ as your Lord and Savior? Radio buttons
Briefly describe your faith journey: 
Paragraph
Willing to participate in Bible study, church, and discipleship? Radio buttons
Any beliefs or practices that conflict with Christian teaching? Radio buttons
Explain: 
Paragraph

Section 7: Program Readiness

What led you to seek help at AHM? 
Paragraph
Have you been to Abundant Hope Recovery Program in the past? Radio buttons
If YES, please tell reason for leaving. Text field
Willing to commit to 12-month program? Radio buttons
Willing to follow all rules and participate fully? Radio buttons
Comfortable living in structured, accountable setting? Radio buttons
How do you feel about serving in our thrift store or service areas? 
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Tell us what is currently happening in your life: 
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If accepted, what date would you be able to enter the program?Date

FEES

There is a one-time fee of $215.00 and a Background check fee of $35 when entering Abundant Hope Recovery Program.
I, Text field, agree to the intake payment of $215.00 and the Background check fee of $35.

By signing below, I voluntarily and knowingly authorize Client or its authorized agents to obtain or prepare consumer reports or investigative consumer reports about me.  I acknowledge receipt of a copy of A Summary of Your Rights under the Fair Credit Reporting Act and certify that I have read this Disclosure and Authorization as well as the summary explaining my rights under the Fair Credit Reporting Act.

Signature:
Signature