Men’s recovery program application

Welcome to the Men’s Recovery Program at Western Carolina Rescue Ministries

We commend you for taking this brave step toward recovery and a renewed life. At Western Carolina Rescue Ministries, we are dedicated to supporting you on this journey with respect, confidentiality, and a deep commitment to your well-being. Our Men’s Recovery Program is designed to provide comprehensive assistance, combining professional guidance with a compassionate approach to address both the challenges of addiction and the opportunities for personal growth. Please complete the following intake form with as much detail as you feel comfortable sharing. Your information will be handled with the utmost care and discretion, helping us tailor our program to meet your specific needs.

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Contact Information

Name
Emergency Contact First Name
We require a valid government-issued photo ID. Can you provide one?
Have you ever been in counseling before?
Registered Sex Offender?
Are you listed in the Sex Offender Registry?
Charged for Child Abuse?

Please list Substance Abuse History in this section.

Any history of mental health treatment? If yes, when and where?
Any history of traumatic event? i.e., neglect, abuse, significant loses, domestic violence, sexual abuse or rape, or exploitation? If yes, when and where?
Do you have a mental health diagnosis? If so, what is it?
Are you taking medication for this diagnosis? If so, what?
Have you been diagnosed for PTSD?
Have you been diagnosed for Anxiety?
Have you been diagnosed for Depression?
Have you been diagnosed for Bipolar Disorder?
Have you been diagnosed for Schizophrenia?

Substance Abuse History

Please complete your mental history in this section.

Detox Needed?
Do you vape or smoke?

Medical History

Please fill out medical history below. *NOTE, we DO NOT take applicants with Methadone MAT. - OK for Suboxone or Subutex.

Are you currently on medication of opiate use disorder?
Allergic to any medications?

Child/Children Information

**** Note – must be pregnant or parenting a child under age 6 to qualify ***

Legal Information

Are there any open warrants?
By submitting this application, I acknowledge and agree to all terms, conditions, and requirements of the Men’s Recovery Program offered by Western Carolina Rescue Ministries (WCRM). I affirm that I meet all the eligibility criteria as outlined and commit to adhering to the rules and guidelines of the program. I understand and accept the faith-based nature of the program, including its incorporation of Biblical Principles. I am aware that providing false or misleading information in this application can lead to disqualification from the program or other actions as deemed appropriate by WCRM. Furthermore, I certify that all information provided in this application is true, accurate, and complete to the best of my knowledge.

Signature for Applicant