Terry s House. Admission Packet

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1 Terry s House Admission Packet Terry s House Intake Department Shared Hope International P.O. Box Vancouver, WA Fax: (360) terryshouse@sharedhope.org

2 TERRY S HOUSE WOMEN S TRANSITIONAL HOME PART ONE: Introduction Admission Criteria Admission Procedure Instructions for Application PART TWO: Admission Application Medical/ Mental Health Acknowledgement and Agreement Form References Release of Information by Shared Hope International Arlington, VA Vancouver, WA 2

3 ADMISSION PACKET PART ONE Thank you for your interest in applying to Terry's House, a Path to Freedom Home Please read all of this information carefully, including this brief introduction. Our Organization: Terry s House is a transitional living program for survivors of sexual exploitation. Our mission is to inspire and empower survivors to heal, grow, and succeed in everyday life. Our hope is that this would be a place of peace and restoration for residents. At the core of everything we do here at Terry s House are four things: Love, Honor, Transparency, and Purpose. Our Program: Terry's House (a Path to Freedom Home) is a Christian residential program that exists to offer young women the opportunity to have their lives transformed and restored in a program that assists to develop successful independent living and self-sustainability. Acceptance into the program requires residents to commit to a minimum stay of 12 months. Length of stay is based on individual life goals of each resident. It is important that applicants take the time to consider whether they are committed to the decision to turn their life around through our transitional living program. Path to Freedom Homes employ Christian counseling, teaching and community involvement to help our residents explore issues such as forgiveness, family and generational patterns, abuse, freedom, faith and principles for life-long success that lead to economic independence. What We Provide: 1. A safe, supportive environment with a staff member on-site. 2. A fully furnished house, including bed linens and towels. 3. A fully equipped and stocked kitchen allowing each resident to prepare their own meals. 4. Resources for continued restoration and well-being. Counseling, mentoring, and weekly coaching meetings help set goals and provide accountability to help meet those goals. 5. Spiritual care. Staff and residents practice daily quiet times, attend weekly church services, and take part in weekly spiritual formation classes at the house. 6. Practical Resources. Staff and volunteers provide Life Skills modules (budgeting, cooking, etc.), as well as work with each resident to connect with job training, internships, and volunteer opportunities. If a resident needs to obtain her GED or would like to attend college, we are committed to helping each resident meet her educational goals by Shared Hope International Arlington, VA Vancouver, WA 3

4 ADMISSION CRITERIA Applicants to Path to Freedom Homes should have a desire to grow and learn in a Christian atmosphere, and be committed to actively apply the principles of a Biblical counseling program. Each applicant must meet the following criteria: 1. Have previously experienced sexual exploitation 2. Adult women between the ages of 18 and 24 years old (Considerations may be made based on individual criteria) 3. Have completed a residential program lasting a minimum of one year, or an equivalent program or have established a history of stability. Stability is defined by references, application and interview. 4. Be clean and sober for a minimum of six consecutive months 5. Minor children are not allowed as residents NOTE: If a referring agency has a resident who will be graduating within three months, that resident may begin the Application Process while completing the current program by Shared Hope International Arlington, VA Vancouver, WA 4

5 ADMISSION PROCEDURE Terry s House will provide room, board and additional oversight, therapeutic, educational and career guidance services for young women (ages 18-24) who have previously or are currently experiencing sexual exploitation. We accept referrals from all agencies. PROCEDURE: I. Application Each applicant should read the admission packet thoroughly to ensure they meet the minimum requirements and are committed to filling the requirements. Applications must be filled out in the prospective resident s own handwriting. If a referring agency would like to ask for any special considerations, please include that with the application. II. Reference Checks Applicants should inform each reference listed that someone from Terry s House will be contacting them, so they can be prepared to respond as quickly as possible as this will expedite the application process. III. Interview Based on application and reference checks, a determination will be made if the Terry s House program is suitable for the applicant and an interview will be scheduled (preferably Skype or inperson). After the interview, the application will be reviewed with the Terry s House Committee. If more information is required, we may ask for additional information and/or may schedule a secondary interview with the applicant (preferably Skype or in-person). IV. Acceptance Upon acceptance, we will notify the applicant and the referring agency to determine a move-in date. If the application is rejected, the applicant and referring agency will be notified. V. Site Visit Whenever possible, a pre-approved visit by the applicant and a representative from the referring agency is encouraged at your own expense by Shared Hope International Arlington, VA Vancouver, WA 5

6 INSTRUCTIONS This Admission Packet includes the following information and should be completed by the applicant entirely in her own handwriting: Admission Application Medical History (include prescribed medications) References Release of Information Form STEP 1: Please submit completed application, including references and Release of Information Form to the Intake Department via (preferred), fax or mail: SHARED HOPE INTERNATIONAL Terry s House PO Box Vancouver, WA Fax: (360) terryshouse@sharedhope.org STEP 2: When the completed application, medical information and references are received, we will present the completed file to the Terry s House committee. If approved, the applicant will be notified and placed on the admission list until a space becomes available. Emergency Admissions Because this is a Phase II program, we do not accept emergency admissions by Shared Hope International Arlington, VA Vancouver, WA 6

7 ADMISSION APPLICATION PART TWO The purpose of this application process is for us to learn more about you and to determine how we can best serve you. We ask that you be as honest as possible. Your answers will be kept confidential. Please ensure every question is answered in your own handwriting. If the item does not apply to you, simply write N/A. We cannot accept incomplete applications. Basic Information Name: DOB: Social Security Number: Current Street Address: City: State: Zip: Phone Number: Address: Are you a U.S. Citizen? Yes No Marital Status: Single Single-Dating Married Separated Divorced Children: Yes No If you have children, list their names and ages: 1. Age: 2. Age: 3. Age: Do you have custody of your children? Do you have a trusted person to care for them while you are in this program? Yes No Emergency Contact Name: Relationship: Street Address: City: State: Zip: Phone Number: Address: 2014 by Shared Hope International Arlington, VA Vancouver, WA 7

8 Education Name of last school/college/university attended? City, State: Grade Completed: Do you have your GED or High School Diploma? Legal/Employment Are you legally eligible for employment in the United States? Yes No Have you ever been employed? Yes No Have you ever been convicted of a crime? Yes No If Yes, please explain: Do you have any felony convictions that would restrict your employment options? Yes No If Yes, please explain: Do you have any outstanding legal issues (pending cases, community service requirements, probation, etc.)? Yes No If Yes, please explain: Have you ever been evicted? Yes No If Yes, please explain: Do you have any outstanding debts or bills in collection? Yes No If Yes, please explain: Do you give permission to Terry s House to do a criminal background check? Yes No 2014 by Shared Hope International Arlington, VA Vancouver, WA 8

9 Residential History Have you been in any other residential programs? Yes No Program Name: Location: Months Resided: Dates: to Reason for leaving: Program Name: Location: Months Resided: Dates: to Reason for leaving: (Additional Programs may be listed on a separate sheet of paper.) Spiritual Have you ever committed your life to God? Yes No Were you raised in a denomination/church affiliate? Yes No Which one? How active are your parents in their faith/beliefs? Do you feel you have a need for God? Yes No Do you read the Bible? Yes No Do you currently attend a church? Yes No Have you ever been involved in any occult activities? Yes No Age? Briefly describe your relationship with God at this time by Shared Hope International Arlington, VA Vancouver, WA 9

10 What are your immediate thoughts when you hear the name Jesus? Are you comfortable talking to God? Do you feel He has ever answered your prayers? Describe: Do you have a favorite Bible Verse? What is it? Emotional What is your greatest strength? What is an area of growth that you are working on or want to work on? What is your biggest victory in life? What is the last book you read? If you could be anything in the world, what would you want to be? 2014 by Shared Hope International Arlington, VA Vancouver, WA 10

11 If you could have happiness or money, which would you choose and why? How do you handle stress? Relationships Describe a trial you had recently and how you overcame it: Are you still in touch with people you met while in the life? Describe the relationship and how you are in contact. Have you ever been involved with a gang? Describe: Describe the relationship you have with your parents: 2014 by Shared Hope International Arlington, VA Vancouver, WA 11

12 Terry s House What made you decide to apply to live at Terry s House? What makes you the most excited about this opportunity? What makes you the most nervous about living at Terry s House? What questions do you have about living at Terry s House? Are you willing to attend counseling while at Terry s House? Yes No Are you willing to attend a drug/alcohol recovery support group? (even if drugs have not been issue it still can help with other addictive behaviors) Yes No Are you willing to meet with a mentor? Yes No Are you willing to attend church and participate in Bible study? Yes No 2014 by Shared Hope International Arlington, VA Vancouver, WA 12

13 Tell us about some things we haven t already asked about. What would you like us to know about you? 2014 by Shared Hope International Arlington, VA Vancouver, WA 13

14 MEDICAL/MENTAL HEALTH Please check all medical conditions that you currently have or have had previously: Anemia Heart Problems Epilepsy/Seizures Stroke Diabetes Migraines HIV/AIDS Fibromyalgia Hepatitis A Irritable Bowel Syndrome Hepatitis B Insomnia Hepatitis C Asthma Other STDs Cancer UTI Fistula Hearing Loss Tuberculosis Blackout Spells/Fainting Emphysema Chicken Pox Broken Teeth/Dental Problems Please check if you have been diagnosed with any of the following: ADD/ADHD Dissociative Identity Disorder Anxiety/Panic Attacks Bulimia Schizophrenia Anorexia Multiple Personality Disorder Depression Borderline Personality Disorder Oppositional Defiant Disorder Bipolar disorder Attachment Disorder Posttraumatic Stress Disorder (PTSD) Premenstrual Dysphoric Disorder Any chance you may be pregnant? Yes No Have you ever tried to commit suicide? Yes No Have you ever cut, burned, or otherwise harmed yourself? Yes No At what age did you start? Have you ever required medical treatment for self-harm (stitches, hospital stay, mental health facility, etc.)? Have you ever experienced rape? Yes No Age? Have you ever experienced domestic violence? Yes No Age? Have you ever experienced sexual abuse? Yes No Age? Have you ever questioned your sexuality? Yes No If yes, explain: Do you smoke? Yes No Check all immunizations that you have received: Polio Tetanus or DPT Measles Rubella Mumps Have you taken a TB test? Yes No Did you pass? Yes No In the past six months, have you been to the dentist? Yes No 2014 by Shared Hope International Arlington, VA Vancouver, WA 14

15 In the past six months, have you received any treatment from a doctor? Yes No Do you have any outstanding medical issues that will require regular care? List all medications you are currently taking: List any allergies that you have: Do you require an Epi-Pen? Yes No List any dietary restrictions/limitations: Were these restrictions/limitations recommended by a doctor? Yes No List any physical or mental limitations that you have: Have you been in any in/outpatient therapy in the last 2 years? Yes No Have you ever participated in a drug treatment program? If so, please list your drug(s) of choice, when you received treatment, and how long you have been clean: Are you currently insured? Yes No Name of the insurance provider: 2014 by Shared Hope International Arlington, VA Vancouver, WA 15

16 By signing below you are agreeing that the above information is accurate and truthful to the best of your knowledge and you release Shared Hope International/Terry s House to verify it: Print Name: Signature: Date: 2014 by Shared Hope International Arlington, VA Vancouver, WA 16

17 REFERENCES Please provide three references that we can contact. Suggestions would be a case manager, mentor, pastor, or current employer. They must be people that you are currently in contact with who know you well. No peers or family members. Please ensure that you have informed your references that we will be calling. The sooner they get back to us, the sooner we can assess the completed application. Counselor Name: Street Address: City: State: Zip: Phone Number: Address: How long have you known this person: Relationship to you: Name: Street Address: City: State: Zip: Phone Number: Address: How long have you known this person: Relationship to you: Name: Street Address: City: State: Zip: Phone Number: Address: How long have you known this person: Relationship to you: 2014 by Shared Hope International Arlington, VA Vancouver, WA 17

18 RELEASE OF INFORMATION All matters relating to applicant are considered confidential by Terry s House, a residential home under Path to Freedom, and are treated as such. Name: DOB: I hereby authorize Terry s House to share information concerning my application to the residential program with the following (examples include: family member, previous employer): 1. Phone: 2. Phone: 3. Phone: I also give the following professional staff (examples include: pastor, medical professionals, rehabilitation staff, law enforcement, case worker) permission to exchange any information with Terry s House for the purpose of my application to the program. Other Professional Staff: 1. Phone: 2. Phone: 3. Phone: I understand that my authorization will remain effective from the date of my signature until, and that the information will be handled confidentially in compliance with all applicable federal laws. I understand that I may see the information that is to be sent, and that I may revoke the authorization at any time by written, dated communication. I have read, understand, and agree to this release. Signature of Applicant Witness Date Date 2014 by Shared Hope International Arlington, VA Vancouver, WA 18

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