Joppa House Ministries - New Resident Application

Dear Applicant,

Thank you for your interest in Joppa House Women's Recovery Homes (JHM). Our recovery residence is a Christ centered pathway to recovery. In the New Testament the apostle Paul mentions the city of Joppa quite frequently in the letters that he writes to the Churches, talking about the times he is praying and taking the time to listen to the Lord for the direction he is supposed to go next. We believe that Joppa House Ministries will be that place for you as well and we look forward to praying for you and working with you in your time here.

Our residents work daily on their life skills curriculum that we have here at JHM with daily progress time sheets, recovery meetings, and working through our 6 Outlooks to Independence and Healing. If accepted into the JHM program, you will be expected to also work daily on the JHM program and the assignments you receive at your weekly Case Management meetings.

JHM exists to mentor women, like yourself, by providing safe and secure housing for each of our residents, while working on budgeting, learning life skills, handling life complications in a sober way, and how to manage post acute withdrawal symptoms in your new found sobriety, as well as through peer support as you reach your milestones.

Within the following pages of the application for residency, please know that any information you provide will not be held against you or used against you in a judgmental way. The JHM staff need to know the facts about you and where you are in your life at the moment so we can figure out how we can best help you as a prospective future resident. Honesty is always the best policy. If a question does not apply to you, please mark it with "N/A". Please do not leave a question blank.

Upon receiving your application for residency we will review it and set up an over the phone interview with you. We will not approve your application for residency without that interview. If you are accepted to the program you will receive a written notice via your email or your case manager's email at the facility you are currently at. At that time, you can use the written notice of acceptance and send a copy to your probation officer or legal representative, if applicable.

We look forward to hearing from you soon!

Very truly yours,
~Pastor Ginger Stevens
Director, Joppa House Women's Recovery Homes
joppahouseministries@gmail.com

New Resident Application

Before continuing with this application, please note the following:

JHM Recovery Residences are not ADA accessible. If you are in need of a wheelchair/walker, we will not be able to accommodate you. We are sorry for any inconvenience.
Our 801 Campus laundry facilities are on the basement level. You will need to carry out your own laundry duties. If you have a physical limitation for stairs, we will not be able to accommodate you. We are sorry for any inconvenience.
With very few exceptions, JHM staff members are not able to provide you transportation to and from your appointments outside of Charlevoix County. Thus, all doctors appointments will need to be referred to Charlevoix County, or you will need to find your own transportation to and from appointments outside of Charlevoix County.

PERSONAL INFORMATION

First Name*

Middle Name*

Last Name*

FULL Street Address*

(ex: 803 State St., Charlevoix, MI 49720)

Phone #:*

Email*

Date of Birth*

(MM/DD/YYYY)

If you have ever been in the MDOC, please provide your DOC #:

Are you currently...? (select all that apply)*

Are you currently receiving Medication Assisted Treatment services?*

Driver's License or State ID#

State Issued

Is your Driver's License suspended?*

If yes, please explain:*

What are your preferred pronouns?

Were you assigned female at birth?*

Weight*

Height*

Eye Color*

Hair Color*

What is your current marital status?*

What category best describes your Race & Ethnicity*

Are you part of the LGBTQ+ community?*

Do you have a Personal Protection Order (PPO) in effect against anyone?*

If you answered yes, what is the PPO Expiration date?

If you answered yes, what is the Respondent's Name?

What is their relationship to you?

Do you own a car?*

Are you a veteran?*

-- * -- * -- * -- * --

REFERRAL INFORMATION

Referral Name*

Referral Organization*

Referral Contact #*

Referral Email*

-- * -- * -- * -- * --

CHILDREN

Do you have any children?*

How many? (please include adult children)*

Children Information*

Please Include: Name, Age, Date of Birth.

Do you have legal custody of your children?*

Are you on any type of government or financial assistance? Please select all that apply.*

If yes, please explain.

-- * -- * -- * -- * --

HEALTH INFORMATION

Are you in good general health?*

If no, please explain.

Do you have a medically verifiable disability?*

Please list any physical limitations that you may have as indicated by a physician:

Do you have any allergies?*

If you said yes, please list the allergies you suffer from.

Please include all food, environmental, and household allergies.

JHM staff have the following allergies:

Spearmint (including mouthwash, gum, toothpaste)
Coconut (including coconut scented shampoos, conditioners, deodorant, and lotions)
Mushrooms

Both the 801 & 803 Campuses are spearmint, coconut, and mushroom free. Please be sure to plan accordingly. We are sorry for any inconvenience.

List any and all medication that you take.

Please include the Medication Name, Dosage, Reason for Taking, and Time Taken.

List all past surgeries or medical hospitalizations

Please include dates where possible.

Do you use tobacco products?*

If you have any dietary restrictions, please share them below:

If you have a special diet, please explain:

Have you been diagnosed with a seizure disorder?*

Have you been diagnosed with Diabetes?*

Do you have any sleeping problems?*

Do you have any dental problems?*

Do you have any behavioral issues we need to know about?*

If you answered yes, please explain:

Do you have a learning disability?*

If you answered yes, please explain:

-- * -- * -- * -- * --

PAST COUNSELING & TREATMENT EXPERIENCE

Have you ever experienced a life altering traumatic event that still affects you? Please explain:*

On a scale from 1 to 10, how would you evaluate your life?*

Have you tried to commit suicide?*

If yes, can you explain why?

Have you ever been to counseling?*

Are you still in counseling?*

Have you ever received psychiatric care or been in a psychiatric hospital?*

If you answered yes, please tell us the name of the Psychiatric Hospital, Location, Length of Stay, and Date of Discharge.

You may be asked to sign a release form from the above facilities and forward those records to Joppa House Ministries.

Have you ever been tested for an STD?*

Note: You may be asked to be tested before entering Joppa House.

When?

Results?*

Have you ever been tested for Hep C?**

*You are required to be tested for Hep C before entering JHM.

When?

Results?*

*If you had a positive result within the last 30 days, the treatment regimen for Hepatitis C must be complete before entering JHM.

Have you ever been tested for HIV/AIDS?**

*You are required to be tested for HIV/AIDS before entering JHM.

When?

Results?*

Have you ever been diagnosed with MRSA?*

If yes, when were you diagnosed?

Have you ever been diagnosed with Scabies?*

If yes, when were you diagnosed?

-- * -- * -- * -- * --

LEGAL BACKGROUND

Are you on Probation or Parole?*

What is the charge you are serving probation for?

Probation/Parole Officer Name

Probation/Parole Officer County

Probation/Parole Officer Email

Probation/Parole Officer Phone #

Completion Date

Are you a Sex Offender?*

Do you have any Open Cases?*

If you answered yes, please explain.

Make sure to add the Status of any Open Cases..

Please explain your Criminal History:

Do you have any Upcoming Court Dates?

Please supply the date of the upcoming court date, the reason for the court appearance, and the location of the court appearance. Make sure to indicate the county of the current or alleged charge, even if you are meeting on Zoom.

Are you currently incarcerated?*

If you said yes, where?

Are you currently on, or will you be on an ankle bracelet?*

Are you a victim of domestic violence?*

Is there a PPO or Restraining Order out on you?*

Any acts of Arson?*

Do you have a history of violence towards yourself, others, or property?*

If you answered YES to any of the above questions, please explain:

-- * -- * -- * -- * --

PAST & CURRENT SUBSTANCE USE

What substances have you experimented with? (Select all that apply)*

What is your drug(s) of choice? (Select all that apply)*

Have you ever been in an alcohol, drug, or detox program?*

If yes, where and when?

Please include the Date of Entry, Program Name, Location, Date of Discharge.
Also indicate if you stayed the full time.

-- * -- * -- * -- * --

MONTHLY INCOME & EXPENSES

Please share your monthly income sources.

Select your monthly income source (select all that apply)*

Please indicate the amount of income you receive from each of the income sources you selected:*

If you don't have any income source, you can answer N/A.

Do you have a bank account in your name?*

Do you have a savings account?*

What is your monthly rent or mortgage?*

What is your monthly cost for Heating/Gas, Electricity, and/or Water?*

What is your monthly fuel cost for your car?*

What is your monthly phone bill?*

What is your monthly cost for streaming services?*

What is your monthly cost for medical insurance, car insurance, and medication expenses?*

Do you have any of the following expenses?*

Select all that apply.

If you selected any of the expenses, please explain.

-- * -- * -- * -- * --

ALL ABOUT YOU!

How did you hear about Joppa House?*

Why are you interested in living at Joppa House?*

Joppa House Ministries is a community living situation that requires consideration and respect for others. You will be sharing living and common spaces for the purposes of sleeping, meal preparation & clean up, dinging, leisure, and work activities. Those with whom you share space with may be of different social, ethnic, racial, and cultural backgrounds.

Do you understand the need for consideration and respect for others in this shared living situation?*

Describe your current recovery goals:*

What do you expect to gain from living at a recovery residence?*

Describe what you have done for your recovery that has been successful:*

Describe what you have done for your recovery that has NOT been successful:*

Do you have individuals in your life that are open to helping you establish recovery? If so, who?*

Please name those individuals who are open to helping you establish a life of recovery.

Are there people in your life who might be unsupportive of your recovery journey?*

What are the best ways that we can support you to help you establish long-term recovery?*

-- * -- * -- * -- * --

REFERENCES

Reference Name #1*

Include both first and last names.

Reference #1 Relationship to You*

Reference #1 Phone Number*

Reference #1 Email*

What organization are they affiliated with?*

If a family member or friend, put N/A.

Reference Name #2*

Include both first and last names.

Reference #2 Relationship to You*

Reference #2 Phone Number*

Reference #2 Email*

What organization are the affiliated with?*

If a family member or friend, put N/A.

Reference Name #3*

Include both first and last names.

Reference #3 Relationship to You*

Reference #3 Phone Number*

Reference #3 Email*

What organization are they affiliated with?*

If a family member or a friend, put N/A.

Emergency Contact Name*

Include first and last names.

Emergency Contact Phone #:*

Emergency Contact Relationship to You:*

-- * -- * -- * -- * --

VERIFICATION & AGREEMENT

I verify that all the information provided as part of this application is truthful and accurate. I also understand that failure to disclose the correct information could lead to my disqualification for residency.

I understand that by typing my name and submitting this form electronically, I consent and agree that my electronic signature is the legal equivalent of my manual or handwritten signature. I consent to receive all related notices, disclosures, and details applying to my application to Joppa House Ministries in this format.

APPLICANT ELECTRONIC SIGNATURE*

Case Manager (First & Last)

Case Manager Organization

Case Manager Contact Info

Email or Phone #

CASE MANAGER ELECTRONIC SIGNATURE

I understand that by typing my name and submitting this form electronically, I consent and agree that my electronic signature is the legal equivalent of my manual or handwritten signature. I consent to receive all related notices, disclosures, and details applying to my client's application to Joppa House Ministries in this format.

JOPPA HOUSE MINISTRIES AGREEMENT

Living at Joppa House Ministries is a privilege and a blessing. The guidelines and values stated on our website in our living agreement are for your benefit, growth, and safety. You are free to leave at any time if you no longer see JHM as a blessing or desire to live outside the guidelines and values of the ministry.

I have read the values for living at JHM and I agree to live by these values. I understand that my case managers will meet with me weekly on Wednesdays in an effort to provide the best care for me and work with me to provide an action plan as I move through the JHM program. I understand that I must participate in the JHM program and if I do not, I will be asked to leave. I understand that the JHM staff are here to help me and want the best for me. I agree to work with them, even if I do not understand the immediate benefit and will do my best to trust the process.

If at any time I no longer desire to abide by the values of JHM, I agree to move out without causing division with backbiting or talking badly about staff, volunteers, or other residents. I understand that if I want to leave, or if I am asked to leave, I will be given seven (7) days to do so, with the understanding that I will agree to maintain involvement with the program and abide by the guidelines, will continue to be caught up with my financial obligation, and agree to maintain my sobriety and peace in the home. I understand that if I do not abide by these guidelines I will be asked to move out within 24 hours.

APPLICANT ELECTRONIC SIGNATURE*

AUTHORIZATION FOR iCHAT BACKGROUND CHECK

I, the undersigned, understand that the above information is required by the central records division of the Michigan State Police, Lansing, Michigan. I authorize Joppa House Ministries to utilize the above information for the sole purpose of obtaining a conviction only criminal history file search. Joppa House Ministries will also be checking the sexual offender registry website. I understand that it is necessary to have a background check done before I am considered for residence at Joppa House Ministry campuses. I understand that the result will not be held against me or prevent me from being considered for residency, but is for confirmation purposes only. I further understand that in certain circumstances the results may also be shared with Joppa House Ministries staff and volunteers. All results expire after one year.

APPLICANT ELECTRONIC SIGNATURE*

joppahouseministries.org • 231-330-2643 • joppahouseministries@gmail.com