Rehoboth Ranch Ministries
Resident Application
The confidential information you share on this application will not be held against you or used to judge you. The Rehoboth Ranch Ministries staff simply needs to know the facts about you and where you are in life right now. Please remember that we will not be able to help you if you are not completely honest when you answer the questions below. Please understand that we absolutely cannot review this application if anything is left blank. If you do not understand what is being requested, please call us and we will be happy to assist you. If a question does not apply it is very important that you mark N/A.
Prior to filling out this application you must have read and understand each of the following documents. Please initial next to each document to indicate you have done so. Pages requiring signatures are indicated by an * in the list below. All applications submitted must include a copy of signature pages from each supporting document.
Applicant Letter *Medical Procedures
*Sample Daily Schedule Visitor Policy
Application Overview Expectations for Residents
*Time Commitment & Phase System *Integrity Commitment
*Resident Application What you can expect to learn at RRM
Name: ______Date: ______
Present Address: ______
Street Address City State Zip
Is this your permanent address? ______(If not, please list your permanent address below)
Permanent Address:______
Street Address City State Zip
Telephone # ( )______Cell Phone # ( )______
Work # ( ) ______Message Phone # ( ) ______
Please describe your current living arrangements: ______
All email addresses where you may be reached: ______
Are you on Facebook? ______Under what names? ______
Are you active on Twitter? ______Under what usernames? ______
Are you active on any blogs / chat rooms / support group websites? (list websites and usernames)
______
Have you ever applied to Rehoboth Ranch Ministries in the past? _____If yes, please give the date ______
Your Main Problems (check all that apply)
_____ Drug Abuse
_____ Drug Addiction
_____ Other: ______
Summary of your current situation:
Why would you like to come to Rehoboth Ranch? ______
______
Why is a faith-based treatment center the best approach for you? ______
______
What are you hoping to gain while at Rehoboth Ranch? ______
______
List your 5 biggest goals in coming to Rehoboth Ranch.
1. ______
2. ______
3. ______
4. ______
5. ______
List your 5 biggest fears in coming to Rehoboth Ranch.
1. ______
2. ______
3. ______
4. ______
5. ______
Referral Source:
_____ Social Services _____ Courts _____ Parents ______Church
_____ Self _____ Probation _____ Counselor ______Other ______
Name of the person who referred you: ______
Contact Info the person who referred you Phone: ( ) ______Email: ______
Information About You
Date of Birth: ______Age: ______City and State of Birthplace: ______
Social Security Number: ______Driver’s License # and expiration date: ______
Height: ______Weight: ______Eye Color: ______Hair Color: ______
Spiritual Background
Do you feel that you have a need for God? ______Explain: ______
______
What is your present relationship with God? ______
______
Have you committed your life to following God?______Date: ______Place: ______
Are you a member of any church or religion? ______
Denominational background: ______
Where do you attend church? ______How often? ______
Do you read the Bible? ______How often? ______
Do you ever pray? ______How often? ______
Have you ever witnessed or been involved with occult activities? (Satan worship, Ouija boards, levitation, rituals, séances, sacrifices, spiritism, voodoo, witchcraft, etc) ______If yes, explain each ______
______
Have you ever been abused in any of these activities? ______
Have you ever been involved in any of the following cults?
_____ Christian Science _____ Mormonism _____ Eastern Religions
_____ Scientology _____ Jehovah’s Witness _____ Kabbalah
_____ Brotherhood _____ New Age Movement _____ Transcendental Meditation
Write a brief explanation of your involvement with each: ______
______
Do your family and friends describe themselves as Christians? ______
Denomination and name of family’s church: ______
Family Relationships
Describe how you get along with your family______
# of siblings you have? ____ sisters ____brothers ____ step / half sisters _____ step / half brothers
Are you adopted? ______Describe your reaction to being adopted: ______
______
Intimate Relationships / Marital Status
____ Single ____ Married ____ Divorced _____ Separated _____ Engaged _____ Serious Relationship
If you are married, is your wife in agreement with you applying to RRM? ______
Are you seeking marital counseling right now? ______Where? ______
Are you currently seriously dating anyone? ______
Children
Do you have any children? ______How many? ______
List names and ages of all children you have given birth to:
1. ______Age: ______DOB: ______
2. ______Age: ______DOB: ______
Who has custody of your children? ______
What arrangements are being made for your children while you are at Rehoboth Ranch? ______
______
Are you on any type of government or financial assistance such as Disability, Food Stamps, etc.? If so, what kind?
Will coming to Rehoboth Ranch have any effect on this assistance? ______
Friendships
Do you find that you are able to make and keep friends easily? ______
How well do you resolve conflict and deal with problems in relationships? ______
______
Do you get along well with people in general? ______
Do you struggle with any of the following?: (check all that apply)
_____ Outbursts of anger _____ Physical violence toward others _____ Aggression
_____ Isolation _____ People pleasing _____ Codependency
_____ Quiet simmering anger _____ Bitterness / Unsolved Problems _____ Jealousy of others
Overall Physical and Medical Health
Are you in general good health? ______
Do you have any medical problems? ______
List any physical limitation that you may have as indicated by a physician: ______
______
Do you have any conditions or events in your past that would limit your ability to fully participate in the
standard RRM program? ______
Do you have any allergies? ______List: ______
List any and all medication that you take:
Medication / Dosage / For what reason? / For how long?List all past surgeries or medical hospitalizations (include dates): ______
______
Past and Current Substance Abuse
Have you ever experimented with the following substances? (Write in the date that you last used that substance.)
_____ Alcohol _____ Hallucinogenic (Acid, LSD, etc) _____ Morphine _____ Inhalants
_____ Crank _____ Amphetamines (Uppers) _____ Opiates _____ Crack
_____ Crystal Meth _____ Barbiturates (Downers) _____ Heroin _____ Tobacco
_____ Marijuana _____ Meth Amphetamines _____ Cocaine _____ Ecstasy
_____ Other (Specify:______)
Drugs of Choice:
1. ______Frequency of use: ______Date of last use? ______
2. ______Frequency of use: ______Date of last use? ______
3. ______Frequency of use: ______Date of last use? ______
4. ______Frequency of use: ______Date of last use? ______
Maximum habit cost per day? ______Longest period clean? ______
Have you ever been in an alcohol, drug, or detox program before? ______
Was it faith based or secular? ______
Date of Entry / Program Name / City / State / Reason for Leaving / Date of DischargeOverall Psychological Health / Past Counseling or Treatment Experience
Have you ever been diagnosed or treated for (please mark yes or no):
_____ DID / Dissociative Disorder _____ ADHD / ADD _____ Schizophrenia
_____ Bi-Polar Disorder _____ Borderline Personality _____ PTSD
_____ Severe Trauma in past _____ Depression Other (______)
Have you ever experienced a life altering traumatic event that still affects your mental health? ______
Please describe: ______
Do experience: _____ Flashbacks _____ Body Memories _____ Nightmares _____ Night Terrors
Do you have trouble sleeping? _____ Why? ______
Have you ever experienced periods of fantasizing / daydreaming for long periods? ______
On a scale from 1 (worst) to 10 (best), how would you evaluate your life? ______
Have you ever tried to commit suicide? ______Why? ______
Have you ever been to counseling? ______Why? ______(List facilities / counselors)
Have you ever received psychiatric care or been in a psychiatric hospital? ______(List facilities)
Please sign release forms with the above facilities/counselors and have your records forwarded to Rehoboth Ranch Ministries.
Sexual Health
Are you sexually active? ______Since what age? ______
Under what conditions? ______
Have you ever been a victim of sexual abuse? ______physical abuse? ______or ritual abuse? ______
Have you ever been a victim of rape? ______or incest? ______How old were you? ______
Have you ever been involved in prostitution? ______For what reasons? ______
Have you ever been in an intimate relationship with another man? ______To what extent? ______
______When? ______How many different relationships? ______
Have you ever contracted an STD? ______Explain:______
Have you ever tested positive for HIV / AIDS? ______Explain:______
Educational Background
Name of last school attended? ______Dates of attendance? ______
Did you graduate? ______If not, what was last grade completed? ______
Have you ever been in special education classes? ______If yes, please list: ______
Do you have plans to further your education? ______
Current Financial Status
Do you have any outstanding debts? ______Explain: ______
______
What arrangements will you make for their payment while you are at RRM? ______
______
Will the finances for your personal needs while at Rehoboth Ranch Ministries be sponsored by a church, ministry,
family, or individual? ______If yes, who? ______
Rehoboth Ranch Ministries provides food and shelter, but we are not responsible for medical expenses or prescriptions. It is your responsibility to cover these expenses. Arrangements should be made prior to residency. If NONE of the above is available to you, please inform the intake coordinator during your interview.
Legal Background
Please send copies of all legal/court documents for all charges, open or closed.
Arrest History
Date / Charge / Legal Outcome / Current StatusDo you have any pending court dates? ______Explain: ______
Are you currently incarcerated? ____ Total Sentence____ Length of time remaining? ______
Name of Attorney or Legal Representative:______
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? ______
Address: ______
Telephone # ( ) ______
Is there anything else you feel the staff at Rehoboth Ranch Ministries needs to know about you, your situation, or your application for residency?
______
______
I have read the rules of Rehoboth Ranch Ministries and agree to submit to the rules and staff at Rehoboth Ranch Ministries. I understand that if I have failed to answer these questions truthfully or purposely withheld information, it can be grounds for either refusal or dismissal from the program.
Please include two 4 x 6 photos of yourself. One needs to be a head shot and one needs to be a full body head-to-toe shot. These do not need to be professionally taken. Upon submission, PLEASE remember to include signature pages of our supporting documents as well as all legal/court documents of open or closed legal charges, if applicable.
______
Applicant Signature Date
______
Witness Signature Date