Welcome. We're glad you're here!
Thanks for reaching out. This form takes about 10 minutes and helps us get to know you before we talk. We’ll start with a few quick questions so we both know if The McCoy House is the right next step. Answer honestly. There are no wrong answers, and everything you share stays confidential.
If you'd rather talk it through, call us at 601.946.0578.
Who is filling out this form?
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If you're not filling this out for yourself, please provide your name, phone number, email address, and your relationship to the applicant:
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A few quick questions first
- The McCoy House is a structured, long-term recovery home for women. These questions help make sure our program fits what you need right now.
1. Are you 18 or older?
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2. Do you need detox, or are you currently in medical withdrawal?
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3. Do you have a medical condition that needs daily nursing or medical care?
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4. Do you have a substance use disorder diagnosis, or are you in recovery from drugs or alcohol?
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5. Have you ever been charged with or convicted of a violent or sexual offense?
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6. Do you have court dates, probation or parole requirements coming up in the next 90 days? *Having a record doesn't rule you out. We just want to understand your needs so we can support you.
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If Yes: Please tell us briefly what's required and how often.
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7. In the last 6 months, have you been hospitalized for mental health, had thoughts of suicide, or needed care for an eating disorder? *Having a mental health history doesn't rule you out. We just want to understand your needs so we can support you.
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If Yes: Please tell us a little about it.
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8. Are you willing to work a 12 step program, attend at least three meetings a week, and get a sponsor within two weeks of moving in?
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9. Are you willing to volunteer at The Real McCoy Thrift Store two shifts a week?
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10. Do you have the financial resources available to pay a $750 monthly program fee?
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About you
Applicant Name:
Client first name
Client last name
Applicant date of birth:
Client birthdate
Applicant address:
Client Address
Applicant phone number:
Client phone
Is it OK to text you?
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Is it OK to leave a voicemail?
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How did you hear about us?
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Referring person or agency:
Client Referred By
Where you are now
Where are you living or receiving care right now?
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Name of the program or facility:
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Expected discharge date:
Date
When would you like to move in? *Move-ins happen Monday through Thursday. We'll confirm a date with you.
Date
Current therapist or case manager:
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Is it OK for us to contact your therapist or case manager? *If you say yes, we'll send you a release to sign before we reach out.
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Your recovery story
Tell us about your treatment and sober living history. *Where you've been, about when, and how it went. A few sentences is fine.
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What is your drug of choice?
Client substances of choice
Which of these diagnoses have you been given?
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If you chose "Other," please indicate your diagnosis below:
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List the medications you take and what each one is for. *Include prescriptions and anything over the counter.
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What health insurance do you have?
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Any allergies?
Client allergies
Getting around
Do you have a valid driver's license?
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Will you bring your car?
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If yes, is it insured, registered, and tagged?
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Emergency contact
Name:
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Relationship to applicant:
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Phone:
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What you're looking for
What are you hoping to get out of your time at The McCoy House?
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What are you ready to commit to right now?
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Are you able to cover program fees?
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Review and submit
That's everything. Thank you for taking the time to share your story with us. It takes courage.
Here's what happens next. A member of our team will reach out within one business day to set up a call. If you have questions before then, call us at 601.946.0578.
CheckboxesI confirm the information I've shared is true to the best of my knowledge.
Please sign and date below.
Signature
Date:
Date