Application for Valley Rescue Mission's
Women and Children's Center
Recovery Program Application Disclaimer & Consent
By submitting this application to Valley Rescue Mission, you acknowledge and authorize the collection of your personal information, including health information, protected health information (PHI), and other sensitive data, for the purpose of evaluating your eligibility and administering program services in accordance with applicable state and federal laws.
You understand that the information provided will be securely stored and processed within One Step, a client management system used by Valley Rescue Mission, and may be accessed by authorized staff for screening, placement, and program administration purposes.
This center is not a medical or psychiatric facility. All prospective clients must be medically and psychiatrically cleared prior to admission. The medical and mental health information requested in this application is required to determine program suitability. If additional medical or mental health documentation is requested, it must be received before a final admission decision can be made. If, within 30 days of admission, it is determined that a client is not appropriate due to undisclosed medical or psychiatric conditions, Valley Rescue Mission reserves the right to refer the client to another facility or back to the referring agency.
Name: Client first nameClient middle nameClient last name Nickname: Client nickname
Address:Client Address
Email: Text field
Phone Number:Client phone
Birthdate:Client birthdate Age:Number field
Emergency Contact:Text field Phone Number:Number field
Sex:Text field
Do you know or are you acquainted with anyone connected to Valley Rescue Mission?Text field
Do you have any family in the Muscogee county area?Text field
Who referred you?Text field
Why are you applying to our Program at this time?Text field
What are your immediate needs?Text field
What are your present goals?Text field
What are your: strengths?Text field
What are your weaknesses?Text field
Do you have a valid driver's license? Text field
Do you have a copy of your birth certificate?Text field
Do you have a copy of your social security card?Text field
Have you ever been arrested?Text field
If so, what were your charges and the arrest date?Text field
Are you on Probation/Parole?Text field
Probation/Parole Office/Officer Info:Probation
Are you a registered sex offender?Text field
If so, were you convicted on or after July 1, 2008?Text field
Have you ever attempted suicide?Text field
If so, when?Text field
Do you have current suicidal thoughts?Text field
If so, when?Text field
Have you been hospitalized for emotional or nervous reasons?Text field
Have you every been in Therapy?Text field
If so, were medications prescribed?Text field
Are you currently in therapy?Text field
If so, please list the therapist:Text field
Are you currently on any medication?Text field
If so, please list:Text field
Do you have a current physicians you are seeing? Text field
If so please list the name : Text field
Have you had any major surgeries in the last 5 years?Text field
Do you have any upcoming major surgeries?Text field
Please provide the following information:
Family MembersEmploymentHistoryEducationHistoryRecoveryHistoryClient sponsor
Are you a Veteran?Text field
Ever received housing assistance?Text field
Do you owe the Housing Authority money?Text field
Are you presently homeless?Text field
Are you currently receiving Medicare/Medicaid, disability or other Government aid?Text field
Are you on food stamps/EBT?Text field
If selected for residence in this program, is there anything that we should know about you that would hinder your ability to sweep, mop, lift, mow, or do normal household chores?Text field
Have you ever struggled with addiction?Text field If not, Please leave this section blank.
Drug of choice:Text field Age of firt use:Number field Longest period of sobriety:Number field
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Amount/How Often
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Date First Used
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Date Last Used
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Cocaine/Crack
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Date |
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Marijuana
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Date |
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Heroin
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Alcohol
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Fentanyl
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Nicotine
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Prewcription Drugs
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Methamphetimines
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Date |
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Kratom
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Date |
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Spice
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Date |
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Other
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Date |
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Do any of these apply to you?
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Childhood
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Teen
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Adult
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Currently
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In therapy For
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Escaping
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None
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Physical Abuse
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Physciological/ Emotional abuse
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Sexual abuse
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Financial Abuse
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Victim of Human Trafficking
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Are you currently experiencing or diagnosed with:
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Yes
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No
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Headaches
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Difficuty Hearing
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Vomiting
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Hemmothoids
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High Blood Pressure
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Low Blood Pressure
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Wear Prosthetic
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Sores or Open Wounds
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Dental Issues
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Diarrhea
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Palpitations
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Numbness
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Use Walking Device
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Lomglasting Sores
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Frequent Ear Aches
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Heartburn or Gas
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Constipation
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Shortness of Breath
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Weakness
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Fatigue
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Joint Pain
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Bruise Easily
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Lice
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Crabs
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Painful Urination
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Vision Issues
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Hearing Aide
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Dizziness
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Abdominal Pain
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Cramping
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Chest Pain
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Neck Pain
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Shoulder Pain
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Back Pain
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Skin Irratation
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Current Injury
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Frequent Urnation
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Unusual Discharge
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Withdraw
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Blackouts
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Mumps
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Renal Issues
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Cancer
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Mental Illness
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Emotional Abuse
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Herpes
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Hallucinations
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Rhematic Fever
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Liver Problems
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Hapatitis
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Heart Disease
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Physical Abuse
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Gonorrhea
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Delirium Tremens (DT's)
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Jaundice
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Arthiritis
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Stroke
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TB
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Syphillis
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Seizures
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Typhoid
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Ulcers
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Diabetes
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Tuberculosis
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Sexual Abuse
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HIV
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AIDS
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Please give a little background about yourself and why you feel this is the right program for you.Paragraph
By signing below, you consent to:
The electronic collection and storage of your personal and health information as described above;
The use of your information by Valley Rescue Mission staff for screening and program purposes;
The sharing of your information with law enforcement or government agencies when required by law.
By continuing, you agree that your electronic signature is the legally binding equivalent to your handwritten signature. Whenever you execute an electronic signature, it has the same validity and meaning as your handwritten signature. You will not, at any time in the future, repudiate the meaning of your electronic signature or claim that your electronic signature is not legally binding.
Applicants Siignature:Signature Date:Date