Microsoft word - admit

Dear Friend: Thank you for inquiring about Saving Grace Home for Women. We are a Christian recovery non-profit organization established in 2007. Many women have had success in recovery at Saving Grace Home for Women. We offer a twelve week, twelve step, faith-based recovery program that teaches life skills using Biblical principles. Daily classes on Christ-centered curriculum and individual and group counseling are used to meet the needs of the whole person (spiritual, physical, mental and emotional). We have enclosed information concerning admission and will be glad to assist you in any way possible. Our office hours are Monday through Friday 9A.M. until 4:30P.M. If you have any questions, please contact our admissions office at 251-946-3355. Sincerely, Halie Jones, LPC Program Director Saving Grace Home for Women Contact Information INFORMATION PACKET
Common Questions
Where is Saving Grace Home for Women located?

From Mobile, AL
Follow I-10 East towards Pensacola. Merge onto AL-59 via Exit 44 toward Loxley/Gulf Shores (7.2 miles).
Turn LEFT onto US-90 for six (6) miles. You will pass Elsanor Elementary School and the Community Center.
We are on the right directly after the Fire Station/Community Center.
From Pensacola, FL
Follow I-10 West toward Mobile. Take Exit 5, US-90-ALT West. Turn left onto W Nine Mile Road/US-90
ALT West/FL-10 West (crossing into Alabama) for 7.1 miles. FL-10 West becomes US-90/AL-16. Continue
for 11.4 miles. End at 23790 US-90, Robertsdale, AL.
How long is the program?
This is a three-month (twelve week) residential program. One (1) year of Aftercare is available for graduates.
Medical criteria
 Client is responsible to reach a safe level of detox prior to admission.  We are NOT a medical facility and CANNOT provide medically supervised detoxification.
 Volunteer medical personnel will assist clients with minor ailments during program.
 Client is responsible for cost of any off-campus emergency medical or dental care and prescriptions that  Client must disclose any physical, emotional, mental or health condition that might restrict or limit her
Medical test required prior to admission
 TB test results (NOT MORE THAN SIX (6) MONTHS OLD)  Pregnancy test results. Pregnant clients must be no more than fifteen (15) weeks pregnant at time of
Approved medications
 All medications MUST BE pre-approved prior to admission and turned in upon arrival.  Examples of approved over-the-counter medications (must be sealed) are as follows: o Pain reliever (i.e. Tylenol, Naproxen, Motrin, Ibuprofen, Aleve) o Stomach medications (i.e. Prilosec OTC, Nexium, Prevacid, Tums, Rolaids, Pepto Bismol) o Cold or sinus medication (i.e. Claritin, Coricidin, Chlortabs, Alka Seltzer Plus Cold Daytime o Cough medications (i.e. alcohol free cough syrup, Delsym, Tussin DM, Tussin CF, cough drops)  Psychotropic medications will be evaluated on a case by case basis. Medications that are not approved
The following medications are not allowed/approved:
 Narcotics, barbiturates, opiate blockers, sleep-aids, mood altering or any potentially addictive
If you have pending legal obligations
 A background check will be done on the applicant.  We ask that every effort is made for all court dates to be postponed while enrolled in the program.  Applicants entering the program must notify their Court/Probation Officer (PO) prior to their admission.  Clients will be permitted contact with Courts, Attorneys and Probation Officers as deemed appropriate by the Program Director and/or Counselor.  Court/Probation officer can contact the Program Director and/or Counselor for more information or to  The Court/Probation officer will be notified in case of dismissal, leaving the program or not fulfilling the financial obligations to Saving Grace Home for Women.
What is the cost?
Saving Grace Home for Women is a non-profit organization that has been faithfully serving women since 2007.
Sponsorship contributions given by individuals, churches and other organizations allow these fees and facilitate
payment options.
 The TOTAL cost of the program is $9,000.00.  Each resident/lady receives a $4,500.00 scholarship at the time of graduation if they complete the entire  The resident/lady is responsible for the remaining $4,500.00 which is broken down into four separate o $1,000.00 is due prior to admission. o $1,500.00 is due at the end of the client’s first month. o $1,000.00 is due at the end of the client’s second month. o The remaining $1,000.00 is due prior to graduation/discharge.  EVERY CLIENT MUST HAVE ON FILE A CREDIT CARD THAT HAS BEEN AUTHORIZED TO USE IN CASE THE ABOVE PAYMENTS ARE NOT MADE ACCORDING TO THE SCHEDULE.
What is the refund policy?
If a client chooses to leave prior to graduation, they forfeit the ability to obtain a $4,500.00 scholarship and are
responsible for paying a per diem rate of $100.00 per day, which is calculated off of the total cost of $9,000.00.
The $1,000.00 deposit is NON-REFUNDABLE.
What forms of payment are accepted?
We accept the following forms of payment: credit card, money order, cash and check.

How do I apply for admission?
Please read the Information and Application for Admission packages carefully before you apply.
 A client who has legal obligations (i.e. court appearances) must submit her application through a legal  A client who has no legal obligations (i.e. court appearances) may submit her own application or have a  Clients should be sure they are fully informed about the following: o Type of program o Policies: medical and legal o Financial obligations: must be fulfilled as agreed in the application and information packet.  All court dates and legal obligations must be postponed until after graduation.  Complete and submit Application for Admission by either fax or mail. o Admissions Office Confidential Fax# at 251-946-3356 o Saving Grace Home for Women  Completed application and ALL required documentation must be received by the Admissions Office  Medical test results must be received by the Admissions Office prior to admission.  Legal representative must attach the follow documents: o Legal status while in the program. o All orders pertaining to the client and Saving Grace Home for Women.  Make sure to include your name, fax and telephone number on the cover sheet.  Your application will be processed immediately by staff, and you will be given a deadline to have an
What if my application is approved?
 Once a client has completed both the Application for Admission and assessment and has been approved for admission, the client will be notified of date and time of admission.  The client must confirm her appointment (i.e. bed reservation) within two (2) business days.  Any appointment not confirmed within two (2) business days will be cancelled. Contact Saving Grace Home for Women to have an appointment rescheduled.  Driver’s license or picture ID must be presented at admission.  If paying by credit card, the credit card must be presented at time of admission.  A confirmation letter of enrollment and scheduled graduation date can be requested at the time of  Emergency contact and/or legal representative will be immediately notified if the client leaves the  The legal representative can contact the client’s counselor for information during the business hours.  Client may request a letter of completion at the time of graduation.
Daily Schedule
o House duties, devotions, scheduled classes (i.e. Bible studies, anger management, financial classes, resumes and interviewing, life skills, self-esteem, therapeutic group counseling, individual counseling, AA/NA meetings, Celebrate Recovery, Living Sober meetings, exercise) o Local church worship service (A.M. service) and Visitation. A client must be at Saving Grace Home for Women for one (1) full week prior to having visitation. o Movies, games, volleyball, sewing, cooking and exercise
Clients are expected to comply with all program rules and procedures and participate in daily scheduled
activities, including house duties.
Visitation
Visitation is every Sunday from 2P.M. until 5:30P.M. On the 1st and 3rd Sunday, Saving Grace Home for
Women offers Family Group. In order for clients to receive visitation on the 1st and 3rd Sunday, their family
must attend the one (1) hour family group prior to family visitation. Clients are allowed to have visitation once
they have been at Saving Grace Home for Women for a full week. Visitors must have a valid driver’s license or
ID.
Ministers or Lay Ministers and church staff may visit with the client by appointment only.

Due to the program schedule, if someone needs to drop off items for a family member that is a client at
Saving Grace Home for Women, he/she will need to contact the Program Director to schedule a time that
will not interrupt the client’s program schedule. Please DO NOT come to Saving Grace Home for
Women campus without an appointment. A visitor may be asked to leave if someone comes to visit
without a scheduled appointment or if it is outside visitation hours. If there are any questions about this,
please contact our Program Director.
Procedures for Visitation:
 Please park and visit in the designated areas.  DO NOT enter the client’s living areas.  Promptly leave at 5:30 P.M.  Please refrain from returning to Saving Grace Home for Women after hours. If someone needs to bring something to a family member, please contact the main office to schedule a time to do that.  Do not bring any prohibited items or any animals.  Only those eligible will be allowed to visit.  We reserve the right to restrict visitation on an individual basis.  We reserve the right to search and/or drug test any and all visitors at the visitor’s expense.
What is the telephone policy?
 EVERY client is given the opportunity to use the phone for ten (10) minutes every day during the  Clients cannot receive incoming calls or faxes unless approved by administrative staff. Tobacco policy
Smoking is allowed at Saving Grace Home for Women and the policy will be explained upon admission.
Can transportation arrangements be made?
Prior to admission (for those who travel a great distance) transportation arrangements can be made to have the
client picked up at Mobile bus station, Mobile International Airport or Pensacola Regional Airport.

What items do I need to bring?
These items are only suggested items:
 Identification documents: Social Security card, driver’s license or picture ID  Bible, AA or NA books  Pen, notebook, three-prong pocket folder, envelopes, stationary and stamps  Robe, night clothes, slippers, shower caddie and shower shoes  Toiletries: mouth wash (alcohol free), shampoo, conditioner, soap, toothpaste, etc.  Personal Hygiene items (enough for three months)  Casual Clothing (no more than ten outfits)  Appropriate attire for church services (up to three outfits)  Appropriate attire for exercise (up to two outfits)  Shorts and dresses must be no shorter than four inches above the middle of the knee.  Pillow  1 bag of candy (16 oz.)  $10 cash. Checks or money orders cannot be cashed.  Tape/CD player optional.  Please make sure that the CDs or tapes that you bring are uplifting. If they appear to glorify addiction or could possibly be a trigger to any of the residents, Saving Grace Home for Women staff will either ask that they be removed or they will be put up until the resident graduates.
What items are prohibited?
 Drugs, alcohol, medication that has not been approved.  All over-the-counter medication must be turned in with unbroken seals. (All medication must be  Anything containing alcohol: mouthwash, cologne, hairspray, etc. Aerosols are not permitted.  Pocket knife or any item that could be considered a weapon.  Cameras, beepers, cell phone, iPod, TV and computer  Books, magazines and/or music are subject to approval by the Program Director.  Jewelry (no facial or body jewelry allowed). Earrings are acceptable.  Clothing with reference to alcohol, gambling, tobacco or profanity or clothing deemed inappropriate by NOTE: All belongings left at Saving Grace Home for Women after a client has left the program will be donated after seven days. PLEASE PRINT AND COMPLETE ALL REQUIRED SECTIONS Received_________ Entered _________ Approved_______ Admission Date____________ Name: ____________________________________________________SSN: ___________________________ Current Address: ___________________________________________________________________________ City: ______________State: _______ Zip: ____________ Age__________ DOB: _______________________ Home Phone: _____________________________Cell Phone: _______________________________________ Email Address:_____________________________________________________________________________ Marital Status: _________________ Race: _______________ Veteran: ___________ Reason for Admission: __________________________Attended Saving Grace Before:  Yes No Currently Employed: ____________________ Employer: ___________________________________________ Employer Address: ________________________________ Phone: ___________________________________ Level of Education: __________________ Driver License#:_________________________________________ Name: _________________________________________ Relationship: _______________________________ Address: __________________________________________________________________________________ City: _____________________________ State: __________________Zip: _____________________________ Home Phone: _______________________________Cell Phone: _____________________________________ Employer: __________________________________Occupation: ____________________________________ Employer Address: ___________________________________ Phone: ________________________________ Responsible Party SSN: ________________________________ C. Emergency Contact Personal Data (must be different from the responsible party listed above) Name: _____________________________________________ Relationship: ___________________________ Address: __________________________________________________________________________________ City: ____________________________ State: __________________Zip: ______________________________ Home Phone: ______________________________ Cell Phone: ______________________________________ Test Results- TB Skin Test: Date Tested ______________ Result: ___________________________________ Pregnancy Test: Date Tested ____________ Result: ___________________________________ Have you ever been in treatment for substance abuse?  Yes No How many times? ______ Have you ever been diagnosed with a psychiatric or mental disorder(s)?  Yes No If yes - list diagnosis _________________________________Date(s) _________________________________ Physician__________________________________________________________________________________ Address: __________________________________________Phone:__________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Do you have any handicaps or limitations, (physical, mental, emotional, medical, dental) that would affect your ability to participate (move, sit, or focus) in this program?  Yes No __________________________________________________________________________________________ List all current prescribed medications, the purpose for medication, and how long you have been taking them. __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Check any that you have abused in past five (5) years What is your primary addiction? __________________________________________ Secondary addiction? ___________________________________________________ G. LEGAL BACKGROUND INFORMATION (This will not affect your admission) Do you have current charges? Yes No Court Date: ____________Where:___________________________ Are you currently on supervision? Yes No Probation Officer’s Name_____________________________________________________________________ Phone: ___________________________________________________________________________________ City, State: ________________________________________________________________________________ Have you ever pled guilty or been convicted of a crime? Yes  No Have you ever been arrested for any sex crimes? Yes No __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ List all arrests, convictions, sentences, prior prison or jail commitments, and probation history. (List places and __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________ Please list all other legal contacts and phone numbers. (attorney, judge, CRO) __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Program cost is $8,500. Each client receives a $4,000 scholarship and is responsible for the remaining $4,500. Included in the $4500 cost is an administrative cost of $1000 which is non-refundable. The first installment of $1000 is due prior to admission, the second installment of $1500 is due at the end of the first month, the third installment of $1000 is due at the end of the second month and the last installment of $1000 is due at the end of the last month and prior to graduation. Contact admissions for questions or to discuss payment options. Type of payment: ___ Credit Card ___ Check ___ Cash ___ Money Order Credit Card Authorization
I, (name on card) _______________________________________________ authorize Saving Grace Home for Women, Inc. to charge my credit card for the following amount of $_________________ on the 1st/15th (circle one) monthly beginning on ________________ until the balance is paid in full. Card No. _______________________________________________________ Exp. _____________ Driver License No. _______________________________________________ State _____________ _________________________________________________________________________________ CCV # (printed on back of card) ________ Signature ___________________________________________________Date __________________ Credit card must be presented the day of admission for the authorization to go through.
The following statement MUST be signed before application will be considered.
Waiver of Liability and Acceptance of Responsibility: I will not hold Saving Grace Home for Women responsible for accidents or injuries that may occur during my enrollment in the program. I also understand that services provided by volunteers in the program are free of charge; therefore, under Alabama Law, I waiver liability from taking legal action against such volunteers for negligence that is neither of a willful or gross nature. I will be responsible for the cost of all off-campus medical care. I authorize Saving Grace Home for Women to share my personal medical information with off-campus medical personnel in case of medical emergencies while I am enrolled in the program. I agree to be responsible for the entire program fee. Furthermore, I understand that Saving Grace Home for Women is not responsible for lost or stolen articles. Signatures: ____________________________________________________________________ Responsible Signatures: ____________________________________________________________________ Client’s Acknowledgement
I, _______________________________________________ hereby acknowledge the following to be true: 1. I have read this entire Request for Admission form and/or have had it explained to me and my questions 2. I understand that Saving Grace Home for Women is not required to admit me to its program. 3. If I am admitted to Saving Grace Home for Women, I understand Saving Grace has the right to dismiss me from the program for just cause as determined solely by and in the sole discretion of Saving Grace 4. That if I am admitted to the program I will abide by all rules of Saving Grace Home for Women and will respect the other clients and the volunteers and staff. Client’s Signature: _______________________________________________Date_______________________ Witness Signature: ______________________________________________ Date_______________________ Application Checklist
Documents Required Before Scheduled Intake ___ Copy of Driver’s License or Photo ID

Source: http://savinggracehome.org/docs/admit.pdf