MERCER COUNTY FELLOWSHIP HOME

                                                                               APPLICATION
             COMPLETE THE ENTIRE APPLICATION - YOU MAY SUBMIT YOUR APPLICATION BY MAIL, FAX OR E-MAIL A SCANNED VERSION__________

MAIL TO: MERCER COUNTY FELLOWSHIP HOME         FAX TO: (304) 327-6234           EMAIL TO:jimmcclanahan1@frontier.com
               421 SCOTT STREET
               BLUEFIELD, WV  24701                                                                CONTACT PHONE #:  (304) 327 - 9876

                                                                          ADMISSION CRITERIA
•        All applicants must be male - 18 years of age and over having a primary diagnosis of a substance use disorder.
•        Every prospect must pass a preadmission alcohol/drug screen, including THC.
•        No narcotic medications - even if prescribed. (all other medications must be approved by the staff)
•        We do not accept Home Plans.
•        We do not accept residents that just want to change their parole or probation officer by moving to this area.
•        Anyone coming from a medical, state, or treatment facility must have medical clearance.
•        No one just looking for a place to stay, we are not a homeless shelter.


                                                                APPLICATION FOR ADMITTANCE
          Print below the name of Agency, Contact Person and Phone Number making this referral;                                  
____________________________________________________________________________________________

Application Date: _________________________        Date Available for Arrival: _____________________________

                                                                  APPLICANT INFORMATION
First Name: _______________________________    Middle: ____        Last: _______________________________

Date of Birth: ______________ Age: ______ (must be 18 or older)    Social Security Number: ______-_____-______

Contact Phone Number(s): ______________________________________________________________________

Current Living Arrangement: Homeless Shelter, Detox Facility, Rehab Facility, other - Street, City, and Sate:  
____________________________________________________________________________________________

Emergency Contact Person: Relationship ________________ Name  _____________________________________

Address (Street, City, State, Phone)________________________________________________________________

Marital Status: _________________ Contact information:  ______________________________________________

Children? (Yes ___) (No ___) If-yes then list age(s): ___________________________________________________

List highest level of education completed: ___________________________

Are you a Veteran of any U.S. Armed Forces? (Yes ___) (No ___) If yes - What Branch: _______________________

Do you have a significant other that is currently in a recovery facility of any type? (Yes ___) (No ___) If Yes - list the

name of that facility and location __________________________________________________________________





(CONTINUED)

                                                                      MEDICAL INFORMATION
Are there any medical conditions that will impede your ability to climb stairs and or prevent you from doing household

and yard chores?  (Yes ___) (No ___)  If yes - Describe your condition: _________________________________

__________________________________________________________________________________________

List all current Medical Conditions: _______________________________________________________________

__________________________________________________________________________________________

Are you currently under a Doctor’s Care? (Yes ___) (No ___) If yes - explain below:

__________________________________________________________________________________________

List ALL current Medications prescribed and over the counter: _________________________________________

__________________________________________________________________________________________

Do you have any medical needs that require special equipment? (Yes ___) (No ___) If yes, explain below:
_________________________________________________________________________________________

                                                                PSYCHIATRIC INFORMATION
Do you have a history of suicide attempts or violence toward yourself? (Yes ___) (No ___) If yes, explain below:

__________________________________________________________________________________________

Do you have a history of violence toward others? (Yes ___) (No ___) If yes, explain: ______________________
__________________________________________________________________________________________

Have you ever been and or are you currently under the care of a psychiatrist and or other mental health professional?

(Yes ___) (No ___) If yes, explain: _______________________________________________________________

__________________________________________________________________________________________

List ALL current Psychiatric Medications:  _________________________________________________________
__________________________________________________________________________________________

                                                                                 LEGAL
Are you currently facing legal issues? (Yes ___) (No ___) If yes - explain _________________________________

__________________________________________________________________________________________

Are you currently on Probation or Parole?  (Yes ___) (No ___) If yes - explain _____________________________
__________________________________________________________________________________________

Have you ever been charged with or convicted of Domestic Violence and or Assaults and or Violent Behaviors?

(Yes ___) (No ___) If yes - explain _______________________________________________________________

Have you been charged with or convicted of a sex offense? (Yes ___) (No ___) If yes - explain below:
__________________________________________________________________________________________
(continued)

(legal - continued)

If yes to “sex offense” above, are you required to register with the state? (Yes ___) (No ___) (N/A ___)

Have you ever been convicted of a DRUG FELONY? (Yes ___) (No ___)  

                                                                        SUBSTANCE USE
What is your substance of choice? (Alcohol, Drugs, if drugs specify) ____________________________________

Have you used I.V. Drugs? (Yes ___) (No ___) If yes - specify IV drugs used ______________________________

When was the last time you used any narcotic and or alcohol? Explain ___________________________________

__________________________________________________________________________________________

                                                                  OTHER INFORMATION
Do you currently have possession of a valid driver’s license?  (Yes ___) (No ___) If No - explain below:

__________________________________________________________________________________________

Do you currently have possession of a valid State Identification Card? (Yes ___) (No ___) If No - explain below:

__________________________________________________________________________________________

Do you currently have possession of a certified Birth Certificate? (Yes ___) (No ___)

Do you currently have possession of a Social Security card? (Yes ___) (No ___)  

Do you currently qualify for WV-EBT? (Yes ___) (No ___) (Not Sure ___) If No - explain below:

__________________________________________________________________________________________

Do you currently have possession of a WV- Medicaid or Medicare Card (Yes __) (No ___) If No - explain below:

__________________________________________________________________________________________

                                                             RESIDENCY REQUIREMENTS
                         (place a [check mark] below to acknowledge your Agreement to the following)

1.        Agree to stay alcohol and drug free. ____     (Failure to do so will result in immediate dismissal)
2.        Agree to random alcohol and drug testing. ____
3.        Agree to ACTIVELY work the NA/AA program and attend all mandatory meetings. ____
4.        Agree to obtain an active twelve step sponsor. ____
5.        Agree to actively work with a Recovery Coach. ____
6.        Agree to respect the rights, views and property of others. ____
7.        Agree to contribute to the cleanliness of the house and property. ____
8.        Agree to abide by all house rules. ____
9.        Agree to pay rent. ____


Applicant Signature _________________________________________    Date Submitted ___________        


     Staff Signature ________________________________________     Date Reviewed ___________