Men's New Life Program application

NOTICE: THESE INSTRUCTIONS ARE IMPORTANT- PLEASE READ CAREFULLY BEFORE APPLYING

Dear New Life Program (NLP) Applicant,

Thank you for your interest in the New Life Program at The Rescue Mission. Please fill out the application carefully and completely.

Your application will be sent to the New Life Program staff committee for review. When there are openings in the program, you will be contacted for an interview.

You will need to call 253-383-4493 every Thursday between 8-10am to keep your name and application on the wait list.

The Tacoma Rescue Mission:

exists to offer God’s Help, Hope and Healing by sharing our Christian faith and striving to provide a permanent pathway out of poverty for people experiencing homelessness in Tacoma and Pierce County.

The New Life Program is:
✓ Christ-centered, because we know that the best hope we can offer to anyone is life transformation through a relationship with Jesus Christ. The New Life Program is open to men of any faith background; participation in Bible studies, Christian discipleship, and Christian church worship services is a required part of the program.

✓ an 8-12 month Christian discipleship and addiction recovery program, providing clean-and-sober housing and meals. The program is full-time and the schedule does not allow for employment until the last phases.

✓ not a state-certified program, so no formal chemical dependency assessments are conducted.

✓ an abstinence-based recovery program. Habit-forming medication is not allowed (narcotic pain medication, methadone, suboxone, marijuana, alcohol and others).

✓ a program with wrap-around services including basic adult education/other individualized education support, career navigation, case management, individual and group counseling, work therapy, service projects, recreational outings and support groups, access to community recovery programs including; Celebrate Recovery(CR), Alcoholics Anonymous(AA), and Narcotics Anonymous(NA), and opportunity to attend and engage in local church community. All program components are mandatory.

Program Eligibility:
✓ 18 years of age or older

✓ Desire for addiction recovery support; willingness to abstain from the use of all mindaltering substances, including alcohol and marijuana

✓ Prepared to enter the program immediately upon acceptance

✓ Homeless and low-income

✓ Able to provide full and honest disclosure of history, current situation on application and in interview

✓ Able to independently provide care for self and living unit (ADLs-basic and instrumental)

✓ Able to share residential space and live in a community setting ✓ No active arrest warrants, no history of sexual offenses

Intake Requirements:
✓ 24-48 hours since last use of drugs/alcohol. Must submit a urine sample for testing at intake interview. If medical detoxification is needed, this must be completed (must provide discharge paperwork) before the intake interview.

✓ Provide picture ID

✓ Provide social security card, or proof of application for replacement card

✓ Signed consent for criminal background check

✓ Complete application for Supplemental Nutrition Assistance Program

✓ Medical and mental health appointments complete; any prescription medication refilled

✓ Release of information signed (for probation officer, other service providers)

Focus Period:

Once accepted into the New Life Program, participants are restricted to TRM/Men’s Campus property for the first 30 days as a Focus Period. The purpose of the Focus Period is to provide rest, safety, and time to get settled and acclimated to the program.

Important appointments should be arranged prior to entry into the program medical, mental health services, etc.

No phone calls, outside appointments, or visitors allowed during the Focus Period, without approval by the Program Manager.

I have read and understand the instructions.

Signature: *

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First and Middle name *

Last Name *

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Email Address *

Have you ever been a client in the New Life Program (NLP) before? *

If yes, what dates?

Are you an NLP graduate? *

Have you ever applied to the New Life Program prior to this application? *

When? (month and year)

Who referred you to the program? *

Are you court-ordered to treatment? If yes, please check with the court about treatment requirements (ex: is state-certified program required.) *

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? *

If yes, what are their ages?

Race/Ethnic origin? *

Are you a Veteran? *

If yes, were you honorably discharged?

Highest education level: *

Do you have any learning disabilities? *

If yes, please describe:

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

Income: *

	$
Disability	$
GAU	$
GAX	$
Retirement	$
EBT-Food Stamps	$
Other	$

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

Substance Use History: Are you currently experiencing any wihdrawal symptoms? *

Please describe symptoms:

List all substance use:

	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?

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 from your addictions? *

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

Please describe:

Legal Issues:

ANY Court Hearing Pending?
*

If yes, list court and dates:

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? *

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?

Medical:

Do you have medical insurance?
*

Name of insurance company?

Height? *

Weight? *

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:

Have you ever used drugs intravenously? *

When were you last tested for the following: *

	Date	Result
HIV/AIDS	Date	Result
Hepatitis B	Date	Result
Hepatitis C	Date	Result

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 ever seen a counselor? *

If yes, when was the last time you were seen?

Have you ever been diagnosed by a counselor/psychiatrist? *

If yes, please explain:

Are you taking any prescription medication? *

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

Is there any reason that you would be unable to participate in any part of the program, including Work Therapy, chores, and recreation activities? *

If yes, please explain:

Recovery takes a lot of hard work and requires you to walk towards and through your past hurts and pain. You need to be willing to devote 8-12 months of your life to finding your identity in Christ Jesus and seeking the healing that He offers.
Your success in this program is determined mainly by your dedication, effort, and willingness to be honest with yourself, God, other program participants and the staff of this program.
We believe that healing takes place only in the context of relationship, so it is critical to learn how to be in right relationship with yourself, God and others. The community setting of the New Life Program provides ample opportunities for these relationships to develop and flourish.
Please answer the following questions as completely and truthfully as you are able.

Why are you applying for the New Life Program? *

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

What are your personal strengths? *

Spiritual Background/Religious Preference:
Note: Being a Christian is not required for admittance to, or participation in, the New Life Program.

How would you describe your religious upbringing?
*

Are you currently attending a church? *

How would you categorize your faith? *

Preferred denomination?

Who is Jesus to you? *

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? *

New Life Program Agreement
I need the New Life Program (NLP) because I have serious life-controlling addictions and issues.

Acknowledge: I acknowledge that I am powerless over my addiction – that my life has become unmanageable. I want change in my life and acknowledge that I need help from others in taking the next steps towards recovery.

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

Relationships: I will live without relationships that conflict with my recovery.

Accountability: I will choose to be accountable to others for my actions.

Responsibility: I will take responsibility for my attitudes, actions, behaviors and choices and will learn about the impact my choices have on people around me.

Residential Units: I understand that the Rescue Mission (RM) provides residential units for participants of the Men’s New Life Program at the Men’s Campus. These units are shared with other program participants and are drug/alcohol free. Exiting from the program will result in my exiting the residential unit, and I must remove my belongings at the time of exit.

Compliance: I agree to comply with the Program Guidelines. I agree to set goals with staff/interns working with me and make continuous progress towards reaching those goals. Failure to progress in any part of my program may be a choice to exit the program. *

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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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