PO BOX 4445 Anniston, AL 36204 Phone: (256) 770-4089 Fax: (256) 770-4530
Long Term Program
STUDENT APPLICATION FOR ENTRY
● THIS FORM SHALL BE COMPLETED AND SIGNED BY THE APPLICANT.
1. Please read and carefully follow instructions. 2. The enclosed application provides 7 Springs/Esther House Ministries with student’s health, medical, psychological, and substance abuse history.
● STUDENTS ARE NOT PERMITTED TO BRING PRESCRIPTION MEDICATION INTO THE PROGRAM WITHOUT APPROVAL. BRING MONEY WITH YOU TO BUY THE MEDICATION NO EXCEPTIONS
● Non-prescription medications– Students are permitted to bring approved non-prescription medications into the program or receive them from outside the program (aspirin, vitamins, etc.). They must be enclosed in the manufacturer's original package with unbroken seal NO EXCEPTIONS
Name: Client first name Client last name Date: Client admit date
Date of Birth: Client birthdate SS#: Text field
Marital Status: Client marital status
Years: Text field Married:Text field Separated:Text field Committed Relationship:Text field
If married, must provide marriage certificate upon entry into the program.
Years: Text field Widowed: Text field Years:Text field
Name of spouse: Text field
Spouse in Program:
Note: Copy of Marriage Certificate must be provided Drivers
Licence number Text field SS#Text field
Food Stamp Number:Text field Pin #Text field
Health Insurance Policy
Provider: Client insurance provider Insurance Plan: Client insurance plan
Group ID: Client insurance group ID Policy#: Client insurance policy #
Address:(Street) (City) (State) (Zip) Text field
Will the insurance company pay for your stay at 7 Springs?
Are you receiving welfare, unemployment compensation, disability payments, workman’s comp, alimony, VA benefits, or other income?
IN CASE OF AN EMERGENCY NOTIFY:
Name: Contact 1 name Phone: Contact 1 phone
Type: Contact 1 type Email: Contact 1 email
Relationship: Text field
Immediate or Emergecy Medical Conditions:
Client health problems
Describe any serious injuries or broken bones:
Describe any treatment and/or medicine you are currently receiving for illnesses, injuries or symptoms noted above:
Please list ALL medications that you would be required to take while in 7 Springs Ministries program. (Bring medications with you):
Medication #1 : Medication 1 name Dosage: Medication 1 dosage
Quantity: Medication 1 quantity Category: Medication 1 category
Frequency: Medication 1 frequency MD: Medication 1 md
Pill count: Medication 1 pill count Discontinued at: Medication 1 discontinued at
Notes: Medication 1 notes
Medication #2 : Medication 2 name Dosage: Medication 2 dosage
Quantity: Medication 2 quantity Category: Medication 2 category
Frequency: Medication 2 frequency MD: Medication 2 md
Pill count: Medication 2 pill count Discontinued at: Medication 2 discontinued at
Notes: Medication 2 notes
Medication #3 : Medication 3 name Dosage: Medication 3 dosage
Quantity: Medication 3 quantity Category: Medication 3 category
Frequency: Medication 3 frequency MD: Medication 3 md
Pill count: Medication 3 pill count Discontinued at: Medication 3 discontinued at
Notes: Medication 3 notes
Medication #4 : Medication 4 name Dosage: Medication 4 dosage
Quantity: Medication 4 quantity Category: Medication 4 category
Frequency: Medication 4 frequency MD: Medication 4 md
Pill count: Medication 4 pill count Discontinued at: Medication 4 discontinued at
Notes: Medication 4 notes
Medication #5 : Medication 5 name Dosage: Medication 5 dosage
Quantity: Medication 5 quantity Category: Medication 5 category
Frequency: Medication 5 frequency MD: Medication 5 md
Pill count: Medication 5 pill count Discontinued at: Medication 5 discontinued at
Notes: Medication 5 notes
List any major operations- START WITH YOUR MOST RECENT-Month/ Year Reason for Operation (USE BACK OF THIS PAGE IF ADDITIONAL SPACE IS REQUIRED):
When were your eyes last examined: Text field
Explain any presenting problems with your eyes:
When were your teeth last examined: Text field
Are you currently experiencing any problems with your teeth:
If yes, please explain: Paragraph
Coffee: Checkboxes Cups consumed per day: Text field
Tea: Checkboxes Cups consumed per day: Text field
Cigarettes:Checkboxes Packs consumed per day: Text field
How would you rate your personal health?
HAVE YOU EXPERIENCED OR DO YOU PRESENTLY HAVE A PHYSICAL AILMENT, INJURY, HANDICAP OR MEDICAL PROBLEM THAT WOULD PREVENT YOU FROM PERFORMING MANUAL LABOR WHILE ENROLLED AT 7 SPRINGS MINISTRIES?
IF YES, PLEASE EXPLAIN:
Please check the box next to the words below that describe you now:
Other: Text field
Is it easy for you to express your feelings?
Do you enjoy being around people?
Would you rather be alone?
What is the presenting problem in your life as you see it? (Explain in your own words why you want
Have you ever been associated with a gang or gang related activity?
Have you ever been abused sexually, physically, and/ or emotionally?
If so, when did the abuse occur?:
Did you report it?
If yes, explain:
Have you ever self-inflicted punishment on yourself (cutter)?
Would you rather feel physical pain than emotional pain?
Have you ever thought about committing suicide?
Have you ever attempted suicide?
If yes, please explain:
Have you ever received mental health treatment not related to drug or alcohol use?
Do you believe in God?
If yes, describe your spiritual encounter if possible:
Do you have a denominational preference?: Text field
Have you ever been involved in the occult
If yes, please explain your involvement:
Is there any information that 7 Springs needs to know so we can better serve you?
What do you plan on doing after the completion of this program?
Are you willing to spend 12-18 months in Christian Recovery?
Do you understand that we are a Christian based recovery program and Christ is the answer to your problems
Why did you become involved with: Text field (Drugs) Text field (Alcohol)
Cost to support substance abuse per day:
Longest time period clean:
Client sobriety date
Method of supporting substance abuse:
Previous occurrence of overdose, withdrawal or adverse drug reactions:
Alcohol, drug and medical counseling (Start with your most recent treatment experience):
Treatment Center #1 Name: Treatment center 1 name
Address: Treatment center 1 address
City: Treatment center 1 city State: Treatment center 1 state Zip: Treatment center 1 zip
Admitted: Treatment center 1 started Discharged: Treatment center 1 ended
Notes: Treatment center 1 notes
Type: Treatment center 1 type
Reason for discharge: Treatment center 1 reason for discharge
Treatment Center #2 Name: Treatment center 2 name
Address: Treatment center 2 address
City: Treatment center 2 city State: Treatment center 2 state Zip: Treatment center 2 zip
Admitted: Treatment center 2 started Discharged: Treatment center 2 ended
Notes: Treatment center 2 notes
Type: Treatment center 2 type
Reason for discharge: Treatment center 2 reason for discharge
Treatment Center #3 Name: Treatment center 3 name
Address: Treatment center 3 city
City: Treatment center 3 state State: Treatment center 3 state Zip: Treatment center 3 zip
Admitted: Treatment center 3 started Discharged: Treatment center 3 ended
Notes: Treatment center 3 notes
Type: Treatment center 3 type
Reason for discharge: Treatment center 3 reason for discharge
Treatment Center #4 Name: Treatment center 4 name
Address: Treatment center 3 address
Admitted: Treatment center 4 started Discharged: Treatment center 4 ended
Notes: Treatment center 4 notes
Type: Treatment center 4 type
Reason for discharge: Treatment center 4 reason for discharge
Treatment Center #5 Name: Treatment center 5 name
Address: Treatment center 5 address
City: Treatment center 5 city State: Treatment center 5 state Zip: Treatment center 5 zip
Admitted: Treatment center 5 started Discharged: Treatment center 5 ended
Notes: Treatment center 5 notes
Type: Treatment center 5 type
Reason for discharge: Treatment center 5 reason for discharge
THE UNDERSIGNED STUDENT APPLICANT FULLY ACKNOWLEDGES THAT THE INFORMATION PROVIDED HEREIN IS ACCURATE AND TRUE TO THE BEST OF HIS KNOWLEDGE, AND THAT THE APPLICATION FORM APPLICANT FURTHER UNDERSTANDS THAT ANY FALSE OR INCOMPLETE INFORMATION MAY CAUSE AND RESULT IN DISQUALIFICATION FROM ADMITTANCE INTO THE PROGRAM, WHETHER A STUDENT IS JUST ENTERING INTO OR IS IN THE PROGRAM.
Student Applicant: Signature
Job assignments are a part of your recovery and you will be accountable to a supervisor for punctuality, job performance, and attitude. There is a chance that you may be transferred to another department at any time. Problems in job performance may result in eviction from the program.
Rules Regarding the Thrift You are to think of working in the Thrift Store as if you were working in a department store. You cannot take anything from the store. It would be considered stealing and the penalty could result in an arrest and property theft charge. Do not take jewelry, shoes, bedding, robes, pajamas, towels, etc. Also do not accept clothing from another resident. If you accept clothes and you did not have authorization to have them, it is considered stealing. You may not set items aside. They must be tagged and put in the thrift store. If you need clothing, please see personnel in the front office. It is not guaranteed that you will be issued a clothing voucher.
Statement of Student Applicant Acknowledgments Regarding Work Assignments, Initial below:
Text field I understand that IF I am admitted as a student, that I will be required to participate in 7 Springs Ministries Work Therapy Program.
Text field I understand that IF I am admitted, I will be performing my work assignments not as an employee of 7 Springs Ministries, but solely for my benefit, to further my spiritual growth and maturity, character development, recovery from controlled substances, and readiness to go back into the workplace.
Text field Accordingly by submitting this Application, I am not applying for a position of employment, and IF admitted, I understand I will not be receive ANY compensation or in-kind benefits in exchange for the performance of any work assignments.
Text field I further understand that if I fail to perform my work assignments, 7 Springs may revoke my status and privileges as a student, not because performance of work assignments are the consideration for the receipt of such status and benefits, but because each student’s participation in the Work Therapy Program is a necessary and vital part of the recovery process.
Text field I have read and acknowledge and fully agree with 7 Springs Ministries ’s description of it’s Work Therapy Program which addresses the importance of my work assignments in helping to build in me the Biblical values of a good work ethic and the character of a responsible, upright individual.
Describe some of your work history:
Employer #1: Employer 1 name Position: Employment 1 position
Started: Employment 1 started Ended: Employment 1 ended
Income: Employment 1 income
Type: Employment 1 type
Notes: Employment 1 notes
Employer #2: Employer 2 name Position: Employment 2 position
Started: Employment 2 started Ended: Employment 2 ended
Income: Employment 2 income
Type: Employment 2 type
Notes: Employment 2 notes
Signature of Applicant: Signature
Name (print): Text field Text field
Following are the non-negotiable issues for 7 Springs: (1) Using drugs and/or alcohol (refusing a drug/alcohol test is considered an admission of use) (2) Threatening student(s) or staff. (3) Verbal and/or physical assault towards student(s) or staff. (4) Consistent defiance towards authority (5) Leaving the premises without permission/not being where assigned. (5) Stealing and/or stashing food items/prescription or non- prescription medicine. (6) Racial or Sexual Harassment. (7) Romantic interludes with another student
If the student shows true penitence and the determination to work toward changing old habits, the Accountability Committee may choose to reinstate the student. A restriction may be imposed, such as a 30- day hold on the program, 30- day restriction with no outside contact.
Name (print): Text field Text field
Signature of Witness: Signature
Name (print): Text field
Student’s Name: Text field Text field
Date of Entry:Date
Family Member’s Name: Text field
Relationship: Text field
Street Address: Text field
City: Text field State: Text field Zip: Date
Phone: Text field
Approved: (Approved by Staff only)
Items Needed: Bible, Notebook Paper, Pens/Pencils. SEE CLOTHING ALLOWANCE PAGE
Student’s Full Name : Text field Text field Date: Date
Staff Members Present: Text field
Amount of Money: Text field Verified By:Text field
Verified By:Text field
Electronic Devices, Cell Phones, etc.:
Applicant Name (print): Text field Text field Date: Date
Applicant Signature: Signature
Staff Signature: Signature
Intake fee for 7 Springs/Esther House Ministries 12-18 month Christian Discipleship Program (residential treatment) is $500 and is due upon entry into program.
Amount Paid: Text field Date: Date
Balance Due:Text field
Any remaining balance must be paid before completing the program.
Staff Signature: Signature
Student Signature: Signature
Student Receipt: Entry Fee
Student Name: Text field Text field Date: Date
Total Amount Due: Text field
Amount Paid: Text field
Balance Due: Text field