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Admission Application Form

Admission Application FormNatalie Teinert2017-07-21T20:13:44+00:00

Admission Application for RHM

Acceptance to RHM

Step 1 of 10

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  • General

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  • Parents/Guardians

  • MM slash DD slash YYYY
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  • Information About You

  • Physical Characteristics

  • Marital Status

  • Children

  • John Smith - 8 Years, Jennifer Smith - 14 Years
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  • Education

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  • Family

  • Pregnancy

  • 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.

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  • Medical

  • 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.

  • (asthma, migraines, thyroid, diabetes, blood pressure, weight issues, heart problems, etc.)
  • Past Surgery Name - Date
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  • Financial

  • (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

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  • Substance Abuse

  • Counseling and Treatment*

  • 1) Date of Entry, Date of Discharge, Program Name, City/State, Reason for Leaving.
    2) Date of Entry, Date of Discharge, Program Name, City/State, Reason for Leaving.
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  • Spiritual

  • Church Name, Pastor Name
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  • Please tell us in 3-5 sentences.
  • Please tell us in 3-5 sentences.
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Restoration House Ministries

PO Box 1101
Victoria, Texas 77902-1101
361-576-4746

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