Prior resident of S.H.? Yes ___ No____ If so, when/reason discharged?
Will you commit to being in this program for 12 to 18 months? Yes____ No____
Do you believe you are powerless over alcohol and/or other chemical substances? Yes____ No____
What are your drugs of choice?
Have you ever taken drugs by IV (intravenous injection)? ____Yes ____No If yes, when was last time? ____________________
Name of Program: Location Date/Yr. Graduation/Completion Date
What are the reasons you wish to come to The Shepherd's House?
Have you ever been arrested or convicted for: murder, arson, terroristic threatening, rape, or any other sexual offenses? ____Yes ____No If yes, please explain:
Do you have any pending court appearances? ____ Yes ____ No If yes, please explain:
Are you or will you be ordered by the court, drug court, probation/parole officer or other legal entity to attend long-term treatment?
____Yes ____No ____ Not sure
Are you currently or will you be on probation or parole? _____Yes _____No If yes, in which county? ___________________________
Name, Phone # and address of Probation or Parole Officer: _______________________________________________________________
A non-refundable application fee of $20.00 must be sent prior to admission. Please make money order or cashier’s check payable to: The Shepherds House, Inc, and mail to Shepherd’s House, 635 Maxwelton Ct, Lexington, KY 40508. Once received, and you have met other basic requirements, you will be eligible for admission to the program. Do you understand this requirement? _____Yes _____ No
Have you spent time in jail/prison? _____ Yes _____ No If yes, when and why?
Marital status? Number of dependents?
Are you ordered to pay child support? ___Yes ___No if yes, how much? How are payments made?
What is the highest grade you have completed? GED? ___Yes ___No
Can you read and write without difficulty? ___Yes ___No
Are you currently taking any prescription medications? If so, you are required to bring written doctor’s orders for all medications at the time of admission. You will also need to have at least a 30 day supply of all medications at the time of admission. List all medications, why it is prescribed and the name of the doctor that ordered the prescription:
Are you currently taking any over-the-counter medications? If yes, what are you taking and why?
Do you have any health/medical problems: _____ Yes _____ No. If yes, please explain:
Can you climb stairs without difficulty? _____ Yes _____ No.
Are you physically able to be employed full-time? _____ Yes _____ No. If not, please explain:
Are you currently employed or have employment pending? ____ Yes ____ No. If yes, name, location and type of employment:
An Admission Fee of $250 is due at the time of admission. Will you be prepared to pay that deposit upon admission? _____ Yes _____ No
Y/N RISK ASSESSMENT Y/N RISK ASSESSMENT
(A) History of harming self?
(E) History of thoughts about committing violence?
(B) History of suicidal thoughts?
(F) History of violent behavior toward property/people?
(C) Current suicidal thoughts?
(G) Current thoughts of harming property/people?
(D) Currently under an EPO?
(H) Do you have an EPO on anyone?
Explain any items checked above.
Do you plan on bringing a vehicle? ___yes ___No If so, you must have a current valid driver’s license, current tag, and proof of insurance. Do you have these? ___Yes ___No (Deposit must be paid in full before a vehicle may be brought onto the property.)
What are your plans should you be released from your current treatment prior to Shepherd's House having an opening for you?
What do you think you will need to do differently now to maintain a clean and sober lifestyle?
Once added to our Waiting list, you must call in once every week, so that we can stay current on your application and let you know of any additional requirements. If you do not call for two weeks, you will be dropped from the waiting list.
Do you understand this? _____Yes ______No
Please return this application to: Sean Schomp. If incarcerated please be sure to include your Prison/Jail ID number and correct mailing address.
You will be notified by mail if you are placed on the waiting list. Please also provide us with the name, phone # and address of a contact person who you speak with on a regular basis (i.e., probation officer, attorney, social worker, jailer, etc.)
Signature: __________________________________________________ Date: _________________________