Student Intake Packet

PO BOX 4445 Anniston, AL 36204 Phone: (256) 770-4089 Fax: (256) 770-4530

www.7springs.org

STUDENT INTAKE PACKET

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.

Divorced:

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Years: Text field Widowed: Text field Years:Text field

Name of spouse: Text field

Spouse in Program:

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Note: Copy of Marriage Certificate must be provided Drivers

Licence number Text field SS#Text field

Food Stamp Number:Text field Pin #Text field

Insurance Information:

Health Insurance: 

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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? 

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Are you receiving welfare, unemployment compensation, disability payments, workman’s comp, alimony, VA benefits, or other income?

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Explain: Paragraph

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

Explain: 

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Describe any serious injuries or broken bones: 

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Describe any treatment and/or medicine you are currently receiving for illnesses, injuries or symptoms noted above:

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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):

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When were your eyes last examined: Text field

Results:

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Explain any presenting problems with your eyes:

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When were your teeth last examined: Text field

Are you currently experiencing any problems with your teeth:

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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?

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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?

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IF YES, PLEASE EXPLAIN:

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PERSONAL AND MENTAL HEALTH HISTORY

Please check the box next to the words below that describe you now:

 

Active Checkboxes

Sloppy Checkboxes

Worthless Checkboxes

Ambitious Checkboxes

Moody Checkboxes

Submissive Checkboxes

Good-natured Checkboxes

Imaginative Checkboxes

Irritated Checkboxes

Introvert Checkboxes

Self-Conscious Checkboxes

Frightened Checkboxes

Extrovert Checkboxes

Lonely Checkboxes

Angry Checkboxes

Shy Checkboxes

Sensitive Checkboxes

Other: Text field

Likeable Checkboxes

Valuable Checkboxes

Other: Text field

Is it easy for you to express your feelings?

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Do you enjoy being around people?

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Would you rather be alone?

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What is the presenting problem in your life as you see it? (Explain in your own words why you want

our help):

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Have you ever been associated with a gang or gang related activity?

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Have you ever been abused sexually, physically, and/ or emotionally?

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If so, when did the abuse occur?: 

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Did you report it? 

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If yes, explain:

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Have you ever self-inflicted punishment on yourself (cutter)?

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Would you rather feel physical pain than emotional pain? 

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Have you ever thought about committing suicide? 

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Have you ever attempted suicide? 

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If yes, please explain:

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Have you ever received mental health treatment not related to drug or alcohol use?

 

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SPIRITUAL HISTORY

Do you believe in God?

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If yes, describe your spiritual encounter if possible:

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Do you have a denominational preference?: Text field

Have you ever been involved in the occult

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If yes, please explain your involvement:

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Is there any information that 7 Springs needs to know so we can better serve you?

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What do you plan on doing after the completion of this program?

Paragraph

Are you willing to spend 12-18 months in Christian Recovery?

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Do you understand that we are a Christian based recovery program and Christ is the answer to your problems

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SUBSTANCE ABUSE TREATMENT HISTORY

Why did you become involved with: Text field (Drugs) Text field (Alcohol)

Paragraph

Cost to support substance abuse per day:

Text field 

Longest time period clean:

Client sobriety date

Method of supporting substance abuse:

Paragraph

Previous occurrence of overdose, withdrawal or adverse drug reactions:

DRUG USED

REACTION (EXPLAINED) FINAL OUTCOME

APPROX. DATE

Text field Text field Text field Text field
Text field Text field Text field Text field
Text field Text field Text field Text field
Text field Text field Text field  Text field

 

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

City: Treatment center 3 state State: Treatment center 3 state Zip: Treatment center 3 zip

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

Date: Date

 

WORK ASSIGNMENTS

 

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.

 

WORK HISTORY

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

 

Skills/Qualifications: Paragraph

Signature of Applicant: Signature

Date:Date

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.

Signature of Applicant: Signature

Date: Date

Name (print): Text field Text field 

Signature of Witness: Signature

Date: Date

Name (print): Text field

 

STUDENT CORRESPONDENCE AUTHORIZATION LIST TELEPHONE and VISITATION (Family Only)

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)

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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)

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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)

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INTAKE PROPERTY CHECK IN

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

Medications:

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Verified By:Text field

Electronic Devices, Cell Phones, etc.:

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Applicant Name (print): Text field  Text field Date: Date

Applicant Signature: Signature

Staff Signature: Signature

Date: Date

 

INTAKE FEE

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.

  • ANY PARTIAL PAYMENTS must be approved by the Executive Director(s).
  • Students are required to apply for food stamps .
  • Students receiving disability are required to donate $350.00 per month.

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

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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

Student Signature: Signature

Staff Signature: Signature