Intake Application
Applicant Information
Applicant Name:
Client first name
Client last name
Date of Birth:
Client birthdate
Age:
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Telephone Number:
Client phone
Email Address:
Client email
Requested move in date:
Date
Tell us a little more about yourself.
Where are you currently living or receiving services?
If you're in treatment or sober living, please provide the name:
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Sober Living & Treatment History
Have you ever lived in sober living before?
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If yes, please provide your sober living history:
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Have you been to inpatient treatment before?
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If yes, please list all treatment facilities:
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Legal & Transportation Information
Do you currently have any legal issues?
If so, please describe:
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Do you currently have a valid driver’s license?
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Do you plan to bring a vehicle with you?
*Note: Vehicle must be insured.
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Clinical & Medical Information
Current Medications & Purpose:
List all medications you currently take and what each one is for (e.g. anxiety, sleep, blood pressure, etc.):
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Please list all of your diagnoses:
(Examples: substance use disorders, depression, anxiety, bipolar disorder, eating disorders, etc.)
Client diagnosis
What health insurance do you currently have?
*Note: The McCoy House does not bill insurance; however, insurance is required for IOP and individual therapy services unless the applicant plans to pay out of pocket.
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What allergies do you have?
Client allergies
Please provide an emergency contact.
Contact Name:
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Relationship (mother, father, friend, sister, etc.):
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Phone Number:
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Email Address:
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Home Address:
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Next, we'll ask you to fill out and sign two releases of information.
1 - for your current facility, therapist, or case manager
2 - for an additional contact person (family, friend, pastor, your emergency contact, etc.)
Release of Information
Current Facility or Therapist/Case Manager
Applicant Name: Text field
I hereby authorize the exchange of confidential information between The McCoy House Extended Care for Women and the parties listed below in ALL the following areas including, but not limited to: medication, treatment plans, aftercare plans, discharge summary, psychiatric testing and assessment, emergency contact, and progress reports. Please provide the information below for the person you are granting The McCoy House to contact.
We need a signed release for your current therapist or case manager. If admitted, we will request that you sign a release for your new therapist in IOP/OP. If you would like to grant us permission to speak with family members, please submit a new release of information for each individual.
Current Facility or Therapist/Case Manager
Name of Facility (if applicable):
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Name of current therapist or case manager:
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Relationship (i.e., case manager, therapist, etc.):
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Address (city, state):
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Telephone Number:
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Signature:
Signature
Date:
Date
Release of Information
Additional Contact
Applicant Name: Text field
I hereby authorize the exchange of confidential information between The McCoy House Extended Care for Women and the parties listed below in ALL the following areas including, but not limited to: medication, treatment plans, aftercare plans, discharge summary, psychiatric testing and assessment, emergency contact, and progress reports. Please provide the information below for the person you are granting The McCoy House to contact.
If you would like to grant us permission to speak with an additional contact, please submit a new release of information for that individual.
Additional Contact
Name:
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Relationship (i.e., family member, friend, emergency contact, pastor, etc.):
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Telephone Number:
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Email Address:
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Address (city, state):
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Signature:
Signature
Date:
Date
Please review our house guidelines and financial information.
After you submit your application, you can download and print it out for your records.
House Guidelines
The McCoy House Extended Care for Women is a structured, compassionate recovery housing program dedicated to helping women heal, rebuild, and thrive in recovery. We provide a supportive environment focused on accountability, personal growth, and community connection.
The following guidelines are in place to create an environment that supports your recovery and ensures the safety and well-being of everyone in the home. The McCoy House is more than a place to stay — it is a community built on respect, accountability, and mutual support.
The reputation of The McCoy House Extended Care for Women reflects the strength and integrity of the women who live here. Therefore, if you choose to make The McCoy House your home, you are committing to conduct yourself in a way that upholds that reputation, both inside and outside the house.
These guidelines are not meant to restrict you, but to provide structure, stability, and consistency — the very things that help foster growth and healing. By following them, you contribute to a safe and nurturing space where all residents can thrive and continue their journey of recovery. You will be expected to adhere to these guidelines as part of your commitment to our program. Please read them carefully and reach out to a staff member if you have any questions or need clarification. We are here to support you every step of the way as you continue your journey of recovery.
Residency Commitment & Expectations
1. A minimum 90-day commitment is required.
2. Residents can be discharged immediately for non-compliance or a consistently negative attitude.
3. As issues arise, staff may create individualized guidelines to best support a resident. Any new guidelines will be written into a contract and signed by the resident and staff.
4. Residents are expected to be positive role models for new residents and assist them during their initial transition into the house.
Sobriety & Substance Use
5. No use or possession of alcohol, drugs, or mood-altering substances is permitted. This includes laxatives, diuretics, steroids, energy drinks, or weight-loss products. *Exceptions: medications prescribed by a physician with signed open consent.
6. Residents may be required to submit to random drug and/or alcohol testing at staff discretion and are responsible for all associated costs.
7. Residents must inform the house manager if they are ill and unable to adhere to their daily schedule. Breathalyzer and/or drug testing may be required.
8. Personal items containing alcohol or questionable substances are prohibited.
Medical & Medication Requirements
9. Residents must submit a list of all medications, including over-the-counter medications.
10. Residents must notify staff of all medical, psychiatric, or dental appointments and any prescriptions written.
11. Residents are prohibited from undergoing elective surgeries, piercings, tattoos, or tanning bed use while residing at the house.
Treatment, Recovery & Programming
12. Residents are required to participate in individual therapy, aftercare, or an intensive outpatient program (IOP), as well as all scheduled McCoy House programming.
13. Residents are required to be actively working a Twelve-Step Program, attend at least three meetings per week, and obtain a sponsor within two weeks of move-in.
14. Each resident must complete a daily schedule accounting for every hour of the day.
15. Residents are required to volunteer at The Real McCoy Thrift Store for at least two shifts per week.
Employment & Education
16. After the first month, residents may apply for a part-time job (up to 20 hours per week), provided all house requirements continue to be met.
17. Residents may pursue educational opportunities with verification of work or school schedules, while still meeting all house requirements.
Behavior, Conduct & Safety
18. No pornographic material, erotica, sex toys, dating sites, cybersex, sexual phone calls, sexually explicit language, or sexually acting-out behaviors are permitted.
19. No violent or sexually inappropriate movies may be viewed.
20. Establishing new sexual or romantic relationships is prohibited while residing at the facility.
21. Residents must respect boundaries and privacy at all times.
22. Residents may not enter another resident’s room without permission.
23. Bedroom doors must never be locked.
24. No weapons of any kind are permitted on the property.
25. Stealing, physical violence, threats, acting out, or use of any weapon will result in immediate discharge and/or legal consequences.
Dress Code
26. Residents must dress appropriately at all times.
-No low-cut, see-through, seductive, or sexually suggestive clothing.
-Shorts, skirts, and dresses must be an appropriate length.
-Clothing with logos related to drugs, alcohol, sex, gambling, or inappropriate language is prohibited.
Curfew, Passes & Visitors
27. Curfew is 10:00 PM daily for the first month.
28. After the first month, Friday and Saturday curfew may extend to 11:00 PM if guidelines are followed.
29. Visitors require prior authorization. Visitors (except sponsors) are not recommended during the first 30 days.
30. After the first 30 days, guest and weekend passes are approved case-by-case.
31. Residents may not travel alone during the first month and must be accompanied by another resident.
32. Residents are prohibited from visiting establishments not conducive to recovery (bars, clubs, casinos, etc.).
33. Residents are strongly discouraged from contact with peers discharged for non-compliance.
Technology & Media
34. Use of social media (including Facebook) is prohibited.
35. Use of personal computers and phones will be monitored and follow referral source recommendations.
36. Televisions are not allowed in bedrooms.
37. Cell phones must be set to silent at curfew.
38. Permission from roommates is required to use phones or computers in bedrooms.
39. Phones may be confiscated if used excessively after curfew.
Household Responsibilities
40. Residents are responsible for personal hygiene, laundry, and cleanliness, including bedrooms and bathrooms.
41. Residents must participate in daily household chores per the posted schedule.
42. Smoking or vaping is permitted only in designated outdoor areas.
43. Candles are not permitted in the house.
Transportation, Vehicles & Mail
44. Vehicles must be licensed, insured, and registered. The McCoy House provides transportation to all required appointments. For everything else, transportation is not guaranteed, though staff may assist when available.
45. Residents may receive mail at the house. Mail received after departure will be returned to sender.
46. Personal belongings left after departure will be donated. Items will not be mailed or stored.
Please review all these guidelines and feel free to contact The McCoy House with any questions you may have. You will be asked to review these and sign them on your move in date.
Financial Information
The monthly rent is $1,500. First payment is due on the first day of arrival. Rent is prorated on the move in date and rent is due on the 1st of every month following move in. A $500 nonrefundable registration fee is due on or before your move in date.
Payments are accepted by check, cash, credit/debit card, or direct deposit to the bank. Please make checks payable to The McCoy House Extended Care for Women. Checks can be mailed to P.O. Box 231, Ridgeland, MS 39158 or dropped off in person. Credit card payments are available by request. Email address of the payor must be provided.
There are no refunds on monthly rent if the resident leaves or is discharged.
All utilities are included in the monthly rent.
A payment schedule will be provided and signed on the move in date.
Scholarship funding may be available.
The McCoy House provides the following items:
1. Community Activities – Equine Therapy, Yoga, Art Classes, Group Outings
2. Sheets
3. Bedspread
4. Blankets
5. Pillows
6. Mattress covers
7. Towels
8. Toilet Paper
9. Paper Towels
10. Garbage Bags
11. Laundry Detergent
12. Household cleaning supplies
13. Coffee
14. Transportation to all required appointments
*Note: The McCoy House does not provide food or transportation for activities or appointments that are not required as part of McCoy House programming.
All done, please click submit. We will be in touch soon. Thank you!