Bridge to Recovery Ministries Men s Recovery Home. Recovery Program Application

Transcription

1 Bridge to Recovery Ministries Men s Recovery Home Recovery Program Application Thank you for your interest in the Bridge House, a ministry of The Bridge Fellowship in North Carolina ( Bridge House ). Before you complete the application, please read the following information carefully. What is the Bridge House? Bridge House is a transitional housing program designed to provide temporary shelter & Biblically-based supportive services so that clients can be forgiven, learn the Bible, regain confidence, seek and keep employment, payoff bills and ultimately move into their own residence. Where is the Transitional Housing Recovery Program located? The transitional housing recovery program provides temporary housing in Kernersville, NC What is the program like? This program provides a shared room in the home. These are NOT private rental rooms and are not leased to clients. The home is furnished, including dishes, pots &: pans, linens, etc., which remain in the home at client exit. What are the requirements for me to be involved with Bridge House? All adults must fill out this application. Adults will attend regular sessions with counselors to work on Bible studies, devotions, School of Discipleship, budgeting, life skills, and employment. Each client is expected to work hard and save money, attend church and be committed to their recovery. Each client will help with the up-keep of the home, the church, laundry facilities, landscaping and grounds. How do I apply? Anyone interested in the Bridge House must submit a written application, in person or via the website. Once a bed is available, the applicant will be invited to an interview. A committee of staff members will visit with each applicant about their needs, concerns, and goals. When they attend the interview, it is helpful to have information about debts and sources of income. At that time, we will provide more details about the program. A decision will be made within 72 hours of the interview as to whether the program is a good fit for the applicant. 1

2 Bridge to Recovery Ministries Men s Recovery Home Program Structure and Guidelines Our program is a Christ-focused, 6 to 9 month residential discipleship program for men who have struggles with addictions. It is built on the foundation of the atoning work of Jesus Christ, and is designed to introduce the resident and family to Jesus and place them in an environment to be discipled. We have taken a simplistic, but understandable, approach to our structure by using the colors of the stoplight, red, yellow, and green. Explanation as follows: RED LIGHT - STOP! Stop what has been going on in the resident s life that has placed him in a situation to enter this program. Stop for 60 days and spend time getting to know the Bible, Jesus, and themselves. During this 60 day period there will be no phones, no outside visitation or correspondence. Any necessary contact or personal needs can be made through a representative of the Bridge House. Residents can expect to help around the Bridge House, the church and other places led by the House Manager. Morning devotionals, minimum 2 hours a day in the Bible and specific reading plans, Bible study, church services and other applicable programs are things that each resident should expect. This is a time where the resident is under the authority of the church, Bridge House Board and House Manager 24 hours a day. NOTED The sixty day black out period could be extended due to infractions of expectation and or rules. There will be no contact with family until the final 20 days of blackout has been determined. YELLOW LIGHT - PROCEED WITH CAUTION! The next sixty days for the resident allows them the opportunity to be introduced back into the community with caution. This caution is to protect the resident. The Bridge House will help to facilitate gaining employment but will provide structure in order to protect the resident from harmful influences and destructive relationships. The resident will be able to work at an approved place of employment. Guidance on employment is as follows. Cannot be self-employed = 5 days of work, 1 day of serving in the church and 1 day of rest Under 50 hours per week Prohibited to work at any past places of employment that have previous influences Must be local to The Bridge House From the time of employment, resident is responsible for $ weekly rent and is also highly encouraged to tithe into The Bridge. We see this scriptural and want to encourage this during their growth in Christ and stay at the Bridge House. Any home leaves and or visitation will be for limited periods. No overnight stays and curfew time remains in effect. All visitations and leaves must be approved by leadership. Leadership has the right to visit any place the resident is at and must know where the resident is at all times. GREEN LIGHT - GO! GO! GO! It has been 120 days. Without any blemishes, attitudes, or corrections the resident has the green light to have more freedom. We have introduced them to Jesus, met and counseled with the resident, encouraged and equipped the resident to live a life in Christ. The resident has a curfew of 9pm on weekdays and 10pm on weekends. We still know where the resident is at all times and resident can go to only approved areas. This is a time where the resident is being introduced back into the community fully. They will be preparing to graduate the program and have a place to live on their own. This time can be anywhere from days depending on any write-ups or issues in the first. 2

3 ****Interviewer, perform drug screening test before moving on. Applicant Name: Phone Number: Today, you took a drug screening test. Will you Pass Fail If fail, what drug(s) will cause you to fail? Where are you living right now? (Circle one) House/Apt. Friends Relatives Shelter Hotel Street Car Other: Address: City/State/Zip Phone: How long have you been staying there? Ever Applied OR Lived at Bridge House before? Yes No Have you been asked to leave your current living situation? Referred to Bridge House by: Bills and Debts: (complete the attached list and add any items not listed) Item Amt Due Mo. Pymnt Past Due? Item Amt Due Mo.Pymnt Past Due? Past Rent Yes/No Pawn Shop Yes/No Cable Yes/No Payday loan Yes/No Electric Yes/No Tickets/Fines Yes/No Gas Yes/No Bankruptcy Yes/No Phone Yes/No Credit Cards Yes/No Water Yes/No Storage Yes/No Student Loan Yes/No Childcare Yes/No Medical Yes/No Auto Payment Yes/No Clubs Yes/No Auto Ins. Yes/No Child Support Yes/No Title Loans Yes/No Repossessions Yes/No Cell/Pager Yes/No Bad Checks Yes/No Other Yes/No INCOME currently received from all sources: Job, Food Stamps, TANF, SSI, etc.: 3

4 If child support is owed to you, please list monthly/total amount owed. Source Monthly Amount Current Case Worker's Name? Phone# Name of Social Services Office: Please explain briefly the reasons for your current situation: Do you receive any medical or counseling services? Name Problem Medication Drivers License Number: State: Expiration: Do you have a car? Yes No Year Model Insurance: Yes No Tag # Current: Yes No State: Current Inspection? Yes No References/Emergency Contact: Name Address Phone # Relationship 4

5 APPLICANT PERSONAL HISTORY Name: Age: SS# Date of Birth: Location of Birth: Married Single Divorced Separated Widowed Previous marriages? Yes No Race (circle): Caucasian African-American Native American Other: Education level (circle): Grades Some College College degree Circle school grade Avg.: A B C D F Name of School Year Graduated High School/GED College Job History Information (Last 5 Years): Year Company Name Pay Rate Duties Reason for Leaving Family Parents Names Address (city, state) Phone # Brothers/Sisters Names Address (city, state) Phone # Do you smoke? Yes No How much per day? Do have a goal to quit and are you willing? Yes No Do you take prescription medications? Yes No If so, please list. Please list any medical conditions you may have. Provide the names of your physicians. (General physician, psychiatrists, specialist etc.) Do you use drugs and/or alcohol? Yes No If yes, which drugs and how often? Method of use? (e.g. smoking, snorting, IV use) For how long? Ever been in drug or alcohol rehabilitation? Yes No If yes, when Name of abused substance Facility 5

6 AA Participant? Yes No NA Participant? Yes No Have you ever been arrested? (DWI, bad checks, assault, etc,) Yes No What for? Have you been a battered person? Did you receive a fine/sentence? Yes No Yes No When? Have you served any time in jail? Yes No How long? Do you have any pending legal issues? Yes No If yes, what for? When is your court date? Are you on parole or probation at present? Yes No How long? Parole/Probation officer Phone # Is there a warrant/s out for your arrest at present? Yes No Reason: 1. In a short paragraph, explain why you wish to be a part of The Bridge House Recovery Program. 2. In a short paragraph explain the circumstances that brought you to seek help from The Bridge House Recovery Program. 6

7 Bridge to Recovery Ministries Men s Recovery Home Recovery Program Rules The following rules of conduct shall be in effect while clients participate in the Bridge House Transitional Housing program. Violation of any rule will, at the sole discretion of the pastors, the Board or staff, be cause for immediate dismissal from the program, causing forfeiture of shelter space & supportive services. 1. No illegal activity of any kind will be permitted. 2. Use or possession of alcohol or illegal drugs is prohibited. 3. Random urinalysis is conducted at the discretion of The Bridge Leadership. 4. Curfew is 9:00 pm for approved activities. Quiet hours are: 10:00 pm through 7:00 am. 5. No overnight guests are allowed. 6. No fighting of any kind will be tolerated. 7. No pets of any kind will be allowed. 8. Smoking is NOT permitted inside Bridge House. 9. Clients must keep Bridge House & common areas clean and neat. 10. All adults in the Bridge House program are expected to follow all rules. 11. All adults must attend scheduled Bible studies, church services, meetings and appointments. 12. Repairs or improvements of the Bridge House must be pre-approved by Bridge House Leadership. 13. Residents are responsible for an upfront fee to enter Bridge House Program. I have read and understand that if I violate any one of these rules I may be dismissed from the Bridge House program. I agree to indemnify, defend and hold harmless The Bridge Fellowship and its ministry Bridge House and/or any other parties associated with this program in any way whatsoever, singly, or collectively, from any blame or liability for injury, misadventure, harm, loss, inconvenience, or damage suffered or sustained as a result of participation in this program or in activities associated therewith. I give permission for information to be released about me, by or to any doctor, social worker, counselor, employer, landlord, shelter, agency or any person deemed necessary by Bridge House. I agree that my acceptance into the Bridge House is not a rental agreement, and that this is not a landlord/tenant agreement, but an application for temporary residency & supportive services provided by the Bridge House program. THE INDEMNITY CONTAINED IN THIS PARAGRAPH (a) IS INDEPENDENT OF TENANT'S INSURANCE, (b) WILL NOT BE LIMITED BY COMPARATIVE NEGLIGENCE STATUTES OR DAMAGES PAID UNDER THE WORKERS' COMPENSATION ACT OR SIMILAR EMPLOYEE BENEFIT ACTS, (c) WILL SURVIVE THE END OF THE TERM, AND (d) WILL APPLY EVEN IF AN INJURY IS CAUSED IN WHOLE OR IN PART BY THE ORDINARY NEGLIGENCE OR STRICT LIABILITY OF BRIDGE HOUSE BUT WILL NOT APPLY TO THE EXTENT AN INJURY IS CAUSED BY THE GROSS NEGLIGENCE OR WILLFUL MISCONDUCT OF BRIDGE HOUSE. Alternative Dispute Resolution. Landlord and Tenant agree to mediate in good faith before filing a suit for damages. Any and all claims or disputes arising from or related to this Lease, other than a claim for injunctive relief, shall first be submitted to mediation in Forsyth County, North Carolina in accordance with the then governing rules of the American Arbitration Association. If the parties cannot resolve their dispute through mediation, they shall have the issue resolved through 7

8 arbitration with the then governing rules of the American Arbitration Association. In Judgment upon arbitration award may be entered in the District Court for the County of Forsyth. Landlord and Tenant shall bear their own costs related to any mediation or arbitration proceeding. Resident Print Resident Signature Bridge House Print Bridge House Signature Date Date Date Date [Attach Photo ID or photograph] 8