Women's New Life Program application

NOTICE: THESE INSTRUCTIONS ARE IMPORTANT & INCLUDE IMPORTANT ELIGIBILITY REQUIREMENTS. PLEASE READ CAREFULLY BEFORE APPLYING

Thank you for your interest in the Women's New Life Program (WNLP) at The Rescue Mission. Please fill out the application carefully and completely.

Incomplete applications will result in a delay for intake interviews. Returning this application does not guarantee acceptance into the program. An interview does not guarantee entrance into the WNLP.

Once this application is received by the Program Manager, she will review it and contact the applicant for a phone prescreen. If the applicant does not have a phone number or email, she will need to contact the Program Manager at 253-383-4493 x 1548 If the Program Manager is unable to contact the applicant via phone or email or does not receive a response from the applicant, the application can not be processed further until contact is made and will be considered inactive (not eligible for the next available opening). The Program Manager will make two attempts to contact applicant and then it is the responsibility of applicant to make contact.

There is no financial cost or fees to participate in the program.

Once an opening in the program becomes available, the Program Manager will contact the first person on the Wait-List and schedule an interview. If she is unable to reach that person or there is no response within two (2) business days, the next applicant will be contacted.

Eligibility Requirements:

While there is no cost to participate in the program, there are income limitations. If you have income, you must present verification of income and it must be at or below the limitations as listed in the table below (in accordance with family size):

Family Size Annual Income Monthly Income

One Person $21,350 $1,780

Two People $24,400 $2,033

Three People $27,450 $2,288

Four People $30,450 $2,538

Five People $32,900 $2,742

✓ You must be at least 18 years old to apply for the program.

✓ If you require detoxification, the NLP does not conduct detox nor arrange for it. Detox must be arranged and accomplished prior to intake by the applicant.

✓ Applicants who are inebriated will not be interviewed. You may be UA’d or given a breathalyzer test.

✓ You cannot be involved in a romantic relationship. Participants in this program must be willing and able to devote their full attention to their own growth and healing while in the program. They must be willing to terminate or suspend any active romantic relationships at the time of admittance to the program and agree to not initiate any romantic relationships while in the program.

✓ A thirty-day FOCUS PERIOD begins upon entry into the program.

o Inform Program Manager of any prior scheduled appointments.

o Program Manager approval required for any phone calls, outside appointments, or visitors.

o Have enough prescription medication to last Focus Period.

✓ The New Life Program (NLP) is an 8-12 month residential recovery program. No outside employment or schooling while participating in the NLP. Employment/education may be authorized during the last phase or as approved by Program Manager.

✓ Our program is Christian based. Although non-Christians are welcome, all clients are expected to attend a Christian Church, Bible studies, and other Christian activities.

✓ ALL pending legal issues (court dates, etc.), with the exception of CPS-related matters, should be resolved prior to consideration for acceptance into the program. Outstanding warrants may prohibit acceptance – these legal issues need to be resolved or discussed with Program Manager prior to admittance.

✓ CPS-involved applicants are accepted on a case-by-case basis. If CPS/court requirements prohibit full participation in the program, we cannot accept applicant.

✓ The program requires a considerable amount of reading and writing. If you are unable to read and comprehend adequately, this program may not fit your needs.

✓ Medical and psychological diagnosis may or may not be an issue for admittance. Each is handled on an individual basis. Some diagnoses are beyond the scope of the NLP to accommodate.

✓ All medications must be disclosed and turned into staff upon admission.

✓ Any applicant taking prescription narcotics, Methadone, or Suboxone will not be accepted.

✓ All applicants must be willing to submit to a UA/breathalyzer on the day of intake.

✓ You must agree to a Washington State Patrol criminal background investigation. A criminal history will not suspend you from application or acceptance to the program. Level 2 and 3 sex offenders are NOT eligible for our program.

✓ There must be full and honest disclosure on this application.

✓ Children living with you must be in school or daycare. We do not provide daycare and you must be able to participate in all elements of the program.

✓ New Life Program Participants purchase and prepare their own food in fully furnished kitchens, so food stamps or adequate income required to meet food needs.

✓ Required ID, Social Security Card, and Medical Insurance information. Please notify Program Manager if you do not have these items.

I have read and understand the instructions. Sign below: *

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First and Middle name *

Last Name *

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Email Address *

NOTE: If it is discovered that you have not been truthful in your responses on this application and during the oral interview, you may be removed from the program. Honesty is important and valued by the WNLP.

Have you ever been a client in the Women's New Life Program (WNLP) before? *

If yes, what dates?

Are you an WNLP graduate? *

Have you ever applied to the WNLP prior to this application? *

When? (month and year)

Who referred you to the program? *

Are you court-ordered to treatment? If yes, bring court paperwork to interview. *

Do you have any other court-ordered requirements (Anger management, victim impact panel, etc.)? *

If yes, please describe:

Age? *

Date of Birth? *

Marital Status? *

Children? *

How many?

Do they reside with you?

Would children visit?

List sex (M/F) and age of each child:

Race/Ethnic origin? *

Are you a Veteran? *

If yes, were you honorably discharged?

Highest education level: *

Do you have any learning disabilities (reading, writing, understanding English, etc)? *

If yes, please describe:

Any Income? Source and amount: *

EMERGENCY DATA: This data is required and must be filled in and accurate.

Emergency Contact Name: *

Relationship to you: *

Emergency contact address: *

Emergency contact phone number: *

Do you have any allergies? *

Please list and describe allergies:

List the top three priorities for you in your life at this time: *

Work History. List your three most recent jobs by date, employer and why you left. *

	Dates From - To	Employer	Why you left
1	Dates From - To	Employer	Why you left
2	Dates From - To	Employer	Why you left
3	Dates From - To	Employer	Why you left

Are you in need of Detoxification at this time? *

List all substance use. The New Life Program is a Substance abuse program and if you do not have an addiction to any substance, you do not qualify and your application will not be considered.

	Drug/Alcohol	Age Started	Do you think you are addicted to it?	Date Last Used?
1	Drug/Alcohol	Age Started	Do you think you are addicted to it?	Date Last Used?
2	Drug/Alcohol	Age Started	Do you think you are addicted to it?	Date Last Used?
3	Drug/Alcohol	Age Started	Do you think you are addicted to it?	Date Last Used?
4	Drug/Alcohol	Age Started	Do you think you are addicted to it?	Date Last Used?
5	Drug/Alcohol	Age Started	Do you think you are addicted to it?	Date Last Used?
6	Drug/Alcohol	Age Started	Do you think you are addicted to it?	Date Last Used?
7	Drug/Alcohol	Age Started	Do you think you are addicted to it?	Date Last Used?

Other compulsive problems *

	Scale 1 Header
	yes	no
Nicotine/Cigarettes	yes	no
Gambling	yes	no
Sexual	yes	no
Pornography	yes	no
Relationships	yes	no
Food/Eating	yes	no
Computer/Internet	yes	no
Television	yes	no
Shopping/Spending Mondy	yes	no
Body Image	yes	no
Lying	yes	no
Procrastination	yes	no

Are you in recovery and worried about a relapse? *

How many times have you made a serious attempt at recovery? *

List all recovery programs in which you have been enrolled:

	Dates	Facility/Program & Location	Inpatient or Outpatient?	Treatment completed?
1	Dates	Facility/Program & Location	Inpatient or Outpatient?	Treatment completed?
2	Dates	Facility/Program & Location	Inpatient or Outpatient?	Treatment completed?
3	Dates	Facility/Program & Location	Inpatient or Outpatient?	Treatment completed?
4	Dates	Facility/Program & Location	Inpatient or Outpatient?	Treatment completed?

What is your longest period of abstinence (sobriety) from your addiction(s)? *

Have you ever been involved in an accountability/recovery group (AA, Celebrate Recovery, etc)? *

Please describe:

Describe your pattern of drug and/or alcohol use in thE last 30 days (frequency of use, binging, etc)? *

Briefly, what do you think has been missing in your past (if applicable) recovery attempts?

Legal Issues:

ANY Court Hearing Pending?
If you have a court date pending, you will not be allowed to enter the program until after the court date and results of the appearance are known. *

If yes, list dates and what for:

Are you a Registered Sex Offender? *

If yes, what level?

Do you have an active warrant? *

If yes, charge and jurisdiction?

Are you currently on probation? *

If yes, charge and jurisdiction?

Divorce/legal separation pending? *

Any child custody issues or other family law issues? *

Debt/Credit issues? *

How much time have you served in Prison? *

How much time have you served in Jail? *

List all prior criminal convictions:

	Conviction	Date	Time Served	State/County of conviction
1	Conviction	Date	Time Served	State/County of conviction
2	Conviction	Date	Time Served	State/County of conviction
3	Conviction	Date	Time Served	State/County of conviction
4	Conviction	Date	Time Served	State/County of conviction
5	Conviction	Date	Time Served	State/County of conviction
6	Conviction	Date	Time Served	State/County of conviction

Do you have a Probation Officer? *

Probation Officers name & phone number:

How often do you have to report?

Does your Probation Officer know you're applying for the New Life Program?

Are you involved with Child Protective Services (CPS)? *

If yes, are you in compliance?

Name/Phone number of CPS Social Worker:

Please list upcoming court of CPS appointment dates:

Medical:

Do you have medical insurance?
*

If so, through whom?

Height? *

Weight? *

Do you have a primary care physician? *

Date of last physical exam? *

What is the general state of your health? *

Are you suffering from withdrawal symptoms right now? *

If yes, describe symptoms:

Do you suffer from any of the following? *

	Scale 1 Header
	Yes	No
Trouble Sleeping	Yes	No
Frequent Headaches	Yes	No
Eye or Vision Problems	Yes	No
ANY Allergies (food, drug, medication)	Yes	No
Blood in Stool	Yes	No
Tremors	Yes	No
Seizures	Yes	No
Difficulty Breathing	Yes	No
Sores that do not Heal	Yes	No
HIV/AIDS	Yes	No
Suicide Attempts	Yes	No
High Blood Pressure	Yes	No
Diarrhea/Constipation	Yes	No
Sexual Issues	Yes	No
Stomach/GI Problems	Yes	No
Liver Problems (Hepatitis?)	Yes	No
Diabetes	Yes	No
Persistent Respiratory (cough, etc)	Yes	No
Any Contagious Condition(s)	Yes	No
Venereal Disease/STD	Yes	No
Other	Yes	No

If other, please list:

Are you currently under the care of a Physician? *

If yes, may we contact them?

Physician's name & contact info:

Are you under the care of a Psychiatrist/Psychologist? *

If yes, may we contact them?

Psychiatrist/Psychologist's name and contact info:

Are you currently under the care of a Therapist? *

If yes, maybe we contact them?

Therapists' name and contact info:

Do you have any chronic medical issues (including vision or hearing loss or dental emergencies)?

	Diagnosis/Condition	Date Started	Under the care of a Physician? Y/N
1	Diagnosis/Condition	Date Started	Under the care of a Physician? Y/N
2	Diagnosis/Condition	Date Started	Under the care of a Physician? Y/N
3	Diagnosis/Condition	Date Started	Under the care of a Physician? Y/N
4	Diagnosis/Condition	Date Started	Under the care of a Physician? Y/N
5	Diagnosis/Condition	Date Started	Under the care of a Physician? Y/N

Have you been diagnosed with any form of mental illness (depression, bipolar, schizophrenia, anxiety, PTSD, etc)? *

List all:

If you have been diagnosed with a form of mental illness, are you under the care of a Mental Health Professional at this time?

If not, when was the last time you were seen?

Are you taking any prescription medication? *

If yes, list all medications (no narcotics or medical marijuana allowed in the NLP at any time):

Do you have sufficient quantity of your prescription medication to satisfy the 30 day Focus Period?

Do you have any disability or ANY physical limitations? *

If yes, list disability/limitations:

Have you been a victim of abuse (sexual, violent physical, emotional)? *

Do you have an anger problem? *

Do you have any difficulty expressing or controlling feelings? *

Spiritual Background

NOTE: Being a Christian is not a prerequisite for admittance to the program, but pay attention to the questions and notes below.

Were you raised in a religious home? *

Are you currently attending a church? *

How would you categorize your faith? *

If non-Christian, please indicate faith (Islam/Muslim, JW, Mormon, etc):

This is a Christian program. All program clients are required to participate in the Christian aspects of the program, including church attendance, faith-based recovery classes and education, devotions, and other activities as assigned. Do you agree to participate? *

NOTE: If you are practicing another faith:

• For the required course work, only an approved Christian Bible may be used.

• You will not be allowed to perform rituals (bowing, chanting, incantations, sacrifices, etc.) associated with your faith within the confines of the WNLP.

• You are not allowed to argue or debate faith against faith.

• You are not allowed to teach tenets of your non-Christian faith.

• Reason: all of these things may pose a stumbling block to young believers within the program.

• Staff welcomes any questions regarding faith and belief. Please seek out a staff member for these questions.

This is a difficult program. You need to be willing to devote 8-12 months of your life to finding your self-worth in Christ Jesus and seeking the healing that He offers. The success of the program relies mainly on your dedication, your effort, and your willingness to be honest with yourself, God, and the staff of this program. Please answer the following questions as COMPLETELY AND TRUTHFULLY AS YOU ARE ABLE. If you require more space, please write on the back.

Why are you applying for the New Life Program? *

What does success look like to you? (Be specific) *

Briefly, please share why you are interested (or not if it doesn't matter) in a Christian program? (Your response has no bearing on your admittance to the program.) *

Women's New Life Program Agreement
I need the Women's New Life Program (WNLP) because I have serious life-controlling addictions and problems.

During my recovery at the WNLP I agree to the following:

Acknowledge: I acknowledge that I am powerless over the effects of the choices I have made thus far in my life – that my life has become unmanageable. I acknowledge that it is necessary for me to submit to authority and that compliance with the guidelines and teachings within the Women's New Life Program (WNLP) can be a beginning to a new, fulfilling, and healthy life.

Alcohol/Drugs:I will live alcohol and drug free.

Relationships: I will terminate or suspend any active romantic relationship prior to entering the New Life Program and I agree not to initiate any romantic relationships while in the Program.

Accountability: I will remain accountable for my actions.

Responsibility: I will take responsibility for my attitudes, actions, behavior, and decisions.

Facilities: I understand that the Tacoma Rescue Mission (TRM) invites applicants into their Women's New Life Program at the discretion of the WNLP staff, and those clients are housed at the TRM facility. The WNLP has authority over the portion of the facilities designated to house WNLP clients. Removal from the program will result in my vacating the WNLP portion of the premises.

Compliance: I agree to comply with the Program Guidelines and the direction of the Women's New Life Program and Tacoma Rescue Mission staff.

*

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Authorization for Release of Information

I hereby authorize THE TACOMA RESCUE MISSION to realease to WASHINGTON STATE PATROL/INTELLICORP the following specified information.
I realease the above named provider from any legal liability the may ariese from this authorization.
Information to be released: Identifying information
Purpose of this release: Washington State Patrol Background Check/ Intellicorp Background Check

I understand my records are protected under the federal regulations governing Confidentiality of Alcohol and Drug Abuse Records, 42 CFR part 2, HIPAA 45 CFR, Washington State Uniform Health Care Act including RCW 70.02 & WAC 388-805, Child/Adult Abuse Information Act including RCW 43.43.830-845 & WAC 446-20-285, Criminal Records Privacy Act RCW 10.97.050 WSP Identification and Criminal History Section, may disclose, upon request, conviction criminal history record infromation and cannot be disclosed without my written consent unless otherwise proved for in the regulations.

I also understand I may REVOKE or RESTRICT this consent at any time except to the extent that action has been taken in reliance on it, and in any event this consent expires automatically as follows: (applicant specify the date, event, or conditon upon which this consent expires, if any):

Signature authorizing release of information: *

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