Admission Application Form - Restoration House Ministries

General
Legal Name*
First Last
Name you go by
Present Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Mobile Phone
Email
Home Phone

Parents/Guardians
Parent/Guardian's Name
First Last
Parent/Guardian's Address
Same as My Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone
Work
How did you hear about Restoration House Ministries ?
Plese Specify
Have you ever applied to Restoration House Ministries in the past?
If YES please give approximate date
MM slash DD slash YYYY

Information About You
Date of Birth
Month
Day
Year
Age
Ethnicity/Nationality
City, State, and Country of Birthplace
City State Country
Passport Number (International Applicants only)
Physical Characteristics
Height
Weight
Eye Color
Hair Color
Marital Status
Marital Status
For How Long? (If Married)
Children
Do you have any children?
How Many?
List Names and Ages
John Smith - 8 Years, Jennifer Smith - 14 Years
Who has custody of your children?
What arrangements are being made for your children while you are at Restoration House Ministries?
Does your coming to Restoration House Ministries have any effect on your custody status?
Explain

Education
Name of last school attended?
Did you graduate?
last grade completed? (If Not)
Have you ever been in any special education classes?
Please List (If Yes)
(USA Applicants only) Do you plan on obtaining a GED or participating in home schooling while at Restoration House Ministries?
Which education option? (If Yes)

Family
Does your family support your decision to come to Restoration House Ministries?
Who has custody of you (if under 18)?
With whom do you live?
Pregnancy
Are you pregnant?
Approximate Due Date
Month
Day
Year
Has a doctor confirmed your pregnancy?
Is the birth father aware of your pregnancy?
What involvement do you anticipate the birth father having with you during your pregnancy?
Which are you considering?
Restoration House Ministries firmly believes in allowing you to make the choice between adoption and parenting. We believe that while you are here God will give you direction for your life and that of your unborn child.

Medical
Do you have any allergies?
List (if Yes)
List any and all medication that you take:
1) Medication, Dosage, Reason, For How Long?
2) Medication, Dosage, Reason, For How Long?
If you have been prescribed medications, please do not stop them on your own, but continue to take them as prescribed by your physician(s). Restoration House Ministries will need a statement from the doctor(s) who prescribed your medication fully explaining the need for this (these) prescription(s). While we do not have a physician on staff, we are blessed with Christian doctors in the community who see the residents and work with us to help evaluate, adjust and taper medications when appropriate.
Medications we do not allow:
Narcotics
Pain pills
Sleeping pills
Anxiety medicine
And most over the counter cold and allergy medicines. We believe in a holistic approach to health and wellness.
Are you on a special diet?
Explain
Was this diet prescribed by a Doctor?
Doctor's Name
First Last
Telephone
Do you eat meat?
Do you have, or have you ever had, a problem with food or eating?
Explain
Have you been diagnosed with an eating disorder, or treated by a physician?
Doctor's Name
First Last
Telephone
List any physical limitations and/or medical conditions that you may have as indicated by a physician:
(asthma, migraines, thyroid, diabetes, blood pressure, weight issues, heart problems, etc.)
Reason
List all past surgeries or medical hospitalizations (include dates):
Past Surgery Name - Date

Financial
Are you on any type of government or financial assistance?
Will your coming to Restoration House Ministries have any effect on this assistance?
Do you have any outstanding debts?
Explain
What arrangements will you make for their payment while you are in the program?
Who will assist you with finances for your personal needs while at Restoration House Ministries ?
(church, ministry, family or individual)
Restoration House Ministries provides food and shelter, but we are not responsible for medical expenses or prescriptions. It is the responsibility of parents or guardians of minors, or their sponsoring agency to cover these expenses. Adult-aged applicants should provide for their own medical needs. Arrangements should be made prior to residency in our program. If none of the above is available to you please inform the Intake Coordinator during your interview.
Legal Background
Have you ever been arrested?
How many times?
Dates, charges, etc.:
Do you have any pending court dates?
Explain
Are you currently incarcerated?
How Long?
Length of Time Remaining?
Name of Attorney or Legal Representative
First Last
Telephone
Have you ever been on probation or parole?
Are you now?
How long?
Length of time remaining
How often do you report?
In person or through mail?
Name of probation or parole officer
First Last
Address
Telephone

Have you ever been a victim of rape?
How old were you?
Have you ever been a victim of incest?
How old were you?
Have you ever been the victim of?
- Sexual abuse (including molestation)
- Physical abuse
- Ritual abuse
Have you ever been involved in prostitution?
Have you ever experienced confusion about your sexuality?
Explain
Have you ever tried to commit suicide?
When?
How?
Why?
Have you ever self - harmed?
How?
For How Long?
Ever required medical treatment for self - harm?
Spiritual
Have you ever witnessed or been involved in occult activities?
Write a detailed explanation of your involvement with occult activities
Have you ever been abused in any of these activities?
Explain
Please describe your previous experiences with any kind of belief practices, including, but not limited to: 1) Brotherhood 2) Jehovah’s Witnesses 3) Scientology 4) Christian Science 5) Kaballah 6) Spiritualist Church 7) Eastern Religions 8) Mormonism 9) Witches and Coven 10) Freemasonry 11) New Age Movement 12) Secret Organizations
Have you ever committed your life to God?
Date
Month
Day
Year
Place
In what Denominational/Church Affiliate were you raised?
How active were your parents in their faith and beliefs?
Are you a member of any church?
Name of church and Pastor
Church Name, Pastor Name
How often do you attend church?
Do you read the Bible?
How often?
Do you ever pray?
How often?
Do you feel that you have a need for God?
Explain
What is your present relationship with God?
Have you ever considered rededicating your life to God?
Are you willing to do it now, if necessary?

Why would you like to come to Restoration House Ministries ?
Please tell us in 3-5 sentences.
What would you like to see happen in your life while in this home?
Please tell us in 3-5 sentences.

Admission Application for RHM

Step 1 of 10

General

Parents/Guardians

Information About You

Physical Characteristics

Marital Status

Children

Education

Family

Pregnancy

Medical

Financial

Legal Background

Substance Abuse

Counseling and Treatment*

Spiritual