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.

Name: Client first nameClient middle nameClient last name

Date: Date

Phone: Client phone Email: Client email

Last Home Address: 

Client AddressClient CityClient StateClient Zip

Date of Birth: Client birthdate Gender: Client gender

SSN: SSN                                       
 
D/L or STATE ID: Text field 
STATE ISSUED: Text field                                   

Please List Other Names Used: Text field

If accepted, what date would you be able to enter the program? 
Date
Tell us what is currently happening in your life:
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Have you been to Abundant Hope Recovery Program in the past?  
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If YES, please tell reason for leaving.  
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Are you willing to complete all phases (immersive, transition and outpatient) of our recovery program? 
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Why is long-term treatment desired?
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Are you disabled:  
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Do you have any longstanding health issues that concern you?
Client health problems
List any ALLERGIES:
Client allergies
Are you pregnant (Female)
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Do you receive Disability, SSI, or any compensation from the Government? 
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List any medications you are currently taking and the reason they are prescribed:
(Approved mental health medications
Prozac (Fluoxetine) Paxil (Paroxetine) Zoloft (Sertraline) Celexa (Citalopram) Lexapro (Escitalopram)
Viibryd (Vilazodone) Cymbalta (Duloxetine) Effexor (Venlafaxine) Trintellix (vortioxetine)

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LEGAL INFORMATION
Probation Details: Probation 
List Probation Officer and Attorney: Contact
TOMIS number: Client Number
Have you ever been convicted of a sexual offense?
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Do you currently have sexual charges pending? 
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Are you required by a judge to complete a recovery program? 
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Judge: Text field County:Text field
List all cases you have been arrested for:
Charge: Text field Court Date: Text field
Charge: Text field Court Date: Text field
Charge: Text field Court Date: Text field
 
DRUG HISTORY
What is your drug of choice: 
Client substances of choice
Do you consider yourself an addict: 
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Explain: Paragraph

FEES
There is a one-time fee of $215.00 when entering Abundant Hope Recovery Program.
By signing I agree to the intake payment of $215.00.
 Signature

By signing 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