El Shaddai’s Refuge, Inc. Intake Application

El Shaddai’s Refuge, Inc. is a men's addiction recovery ministry located in southern Laurens County just outside of Dublin, GA. We
are situated on approximately 45 acres near a freshwater spring and the Oconee River. We provide men with an environment and
recovery program to overcome substance use disorder. Our goal is to equip men with an opportunity to gain needed skills to return
to society as a productive citizen. The tools utilized are: continued abstinence through 12-Step Meetings, Biblical applications for
living, life skills, relationship skills, educational needs, job preparation, budgeting skills. El Shaddai’s Refuge is a 12 - 18 month
commitment. A resident’s program length is determined using many factors.

Candidates for admission must complete this application and have an in-person or phone interview with the director. False or
misleading information could result in denied admission or in being discharged when this becomes known.

Requirements for Admission:
● Be a biological male between ages 25 and 55.
● Agree to abide by all guidelines, fully participate in all aspects of the program, and refrain from any activity staff deems
contrary to recovery or good moral character. (Director reserves the right to enact disciplinary measures or dismissal from
El Shaddai's Refuge for any violations.)
● Be physically able to work.
● Be medically able to fully participate in a program that does not provide medical care, dental care, or assistance with
medications.
● Be mentally stable and capable of functioning in the El Shaddai's Refuge environment; able to participate in 12-Step
Meetings, in-house meetings, and church as well as participate in group discussions, written work, and study assignments.
● Be willing to refrain from the pursuit of all romantic relationships (excluding your spouse to whom you are legally
married) while residing at ESR.
● Avoid drugs and alcohol.
● Avoid other mind-altering substances, which can be available over-the-counter and in some energy drinks. (Follow staff’s
directions).
● Avoid tobacco / nicotine and vaping on or off campus.
● Possess no electronic device (cell phone, tablet, laptop, etc.) until approved by staff. All new residents are required to be
device free but will be allowed to use the ministry phone to call trusted contacts at least once a week.
● Understand that not until after 30 days will a resident qualify for a Sunday visitor (church attendance only; must meet
standards for visitation as outlined in the Resident Handbook).
● Pay the non-refundable intake fee ($1,000) and first 4 weeks fees ($1,400) totaling $2,400 at intake.
● Maintain the weekly $350.00 program fees.
● Each resident is limited to an amount of clothing and personal items that he will store in an assigned chest-of-drawers and
an assigned section of a shared walk-in closet. We do not have space to store extra belongings.
● MUST PASS DRUG TEST the day of intake to El Shaddai's Refuge and willing to take periodic drug tests throughout the
stay.
● Submit to a criminal background check.
● MUST bring a photo ID to intake.

 

 

Receipt of this application does not guarantee acceptance. An applicant must have a written
confirmation from the El Shaddai's Refuge director that he has been accepted.
This application form should be completed by the applicant, but a trusted family member / friend, case
worker, accountability court coordinator, or other authorized person may complete this if necessary.

Last Name:Client last name First Name:Client first name Mi:Client middle name

Date of Birth:Client birthdate Email:Client email Race:Client race

Mailing Address:Client Address

City:Client City State:Client State Zip Code:Client Zip

Home Phone:Client phone Cell Phone:Client phone Other:Client phone

SSN:SSN Driver License No:Text field

Religion/Religious Background: Text field  Gang Affiliation?:  Text field  If Yes, explain:Text field

Occupation/Previous Work: EmploymentHistory

List the substances you have abused. Begin with your drug of choice. (i.e., alcohol, marijuana, cocaine, prescription drugs, etc.): Client substances of choice

Have you ever before been in a drug and alcohol program? Text field

If yes, name the most recent program: TreatmentCenterHistory

How did you hear about El Shaddai's Refuge? Text field

Marital Status:Client marital status

Number of Children:Text field Pay Child Support?  Text field

List any physical disability / handicap: Text field

Are you on Disability, SSI, etc? Reason:Text field

 

 

 

 

Emergency Contact Information

Contact

Community Supervision Officer, DFCS Representative, Court Representative,
and/or Other Supervising Authority

Name: Text field        Phone:Text field

Email:Text field         Frequency of Check-In:Text field

 

Medical Issues/Medications

List any current medications prescribed to you: Medication And why:Text field

Do you have any known medical or dental problems (including allergies to food, medicine, etc.)?  Text field

If yes, describe here: Text field

List any mental health treatment (give diagnosis if known):Client diagnosis 

And any medications prescribed: Text field

Have you ever attempted suicide or a suicidal action?  Text field

If yes, give date(s) from the last 5 years: Text field

 

Legal Issues

Do you have any court case(s) pending?  Text field  If Yes, explain:Text field

List your record of criminal charges, jail time, and / or prison time (if applicable)Criminal History

Are you a registered sex offender or have a sex charge?   Text field  If Yes, explain:Text field

Have you ever been convicted of a violent crime?   Text field  If Yes, explain:Text field

 

 

Education

Highest level of education: Dropdown

 

Financial Status

Are you able to pay your initial fees?  Text field 

If “No” do you have someone to help pay your initial fees?  Text field

If “Yes” give name and phone number:Text field

 

 

Statement of Commitment

Initial beside each of the following statements to show agreement:

Initials Text fieldI will comply with all the requirements of admission as well as the rules of ESR as stated in the Resident Handbook.
Initials Text fieldI have obtained written permission from legal supervision for entering the ESR program (if applicable).
Initials Text fieldI am willing to participate in this Christian faith-based program.
Initials Text fieldI am willing to participate in 12-step meetings and group meetings.
Initials Text fieldI will refrain from activities that the staff deem contrary to recovery and personal growth.
Initials Text fieldI agree to refrain from the pursuit of all romantic relationships (other than with my spouse with whom I am legally married) while at ESR.
Initials Text fieldI am physically and mentally able to fully participate in all aspects of this program (including work assignments).
Initials Text fieldI am willing to do whatever is necessary to be clean and stay clean of drugs and alcohol.
Initials Text fieldI , the applicant, personally completed this application? If no, who did?Text field

Applicant's Signature:Signature Date:Date

If this form was completed by an authorized person - not the applicant, that person should sign his / her own name.