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 ___________