EXODUS HOUSE TULSA APPLICATION

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1 Name DOC# Date mailed Do you attend Redemption Church EXODUS HOUSE TULSA APPLICATION 2624 E. Newton St., Apt. E Tulsa, OK Phone: (Do not fax application) 1

2 Exodus House Application Please read carefully and send General information page, Authorization to Release Information, and current CRC card to the address on the front page of the application. Please be sure to send three items back to us. God Bless! Exodus House is a faith based ministry sponsored by the United Methodist Church for men and women being released from prison. We provide rent free housing for six months and a supportive, spiritual community. Due to the size of the apartments, we are not able to accommodate residents with children. However, we will consider weekend visits and other arrangements with children on an individual basis. Our residents must agree to abide by all Exodus House rules and guidelines. We have zero tolerance for drugs, alcohol, negativity, or anything illegal. There is a 10pm curfew (midnight on weekends), random drug test, chores, and mandatory employment. We require counseling and recovery meetings when applicable. No visitors are allowed in the resident s apartment without consent of staff. Each resident must pay utilities and save $400 each month. Each apartment is furnished and if the resident successfully completes the program, he or she can keep the furniture (does not include major appliances). Each week the resident must attend Redemption Church twice and community meeting once. They must attend the church which sponsors their apartment once a month as well. We are a program; not simply a place to live. We expect that our residents desire to change their life and behavior. Due to our location we are not able to accommodate sex offenders. Violent offenses will be considered on an individual basis. 2

3 EXODUS HOUSE / TULSA PROGRAM COMPLETETION REQUIRMENTS 1) Residents will obtain a job as soon as possible and then seek more permanent employment at a living wage. 2) Residents will have attended 90% of all Redemption Church and Exodus House programs. 3) Residents will follow all Exodus House Guidelines and will abstain from the use of drugs and alcohol. 4) All community hours will be completed and documented, 8 per month. Exodus House chores will be completed on a weekly basis. Please note that community service and Exodus House chores are not the same thing. 5) Residents are required to attend sponsor church once a month, additional attendance is encouraged. 6) Residents are required to save $400 per month. They are also required to pay utilities. Savings and utilities can be caught up once employment is obtained. 7) Counseling is required as suggested by Exodus House staff, 6 sessions will be paid for by Exodus House. If staff or counselor recommends continued counseling residents will pay the reduced fee of $25 per session. 8) More than 3 infraction reports will be grounds for termination from program. 9) Residents will attend recovery programs dealing with their issues on at least a weekly basis. Not every action that a resident is held accountable for is in writing due to the impossibility of putting every possible situation in writing. Therefore it is the responsibility of the resident to ask first before engaging in questionable activity. Therefore, excuses such as I didn t know will not be tolerated. 3

4 General Information (Send this page back) Name Doc# Highest Education Completed GED (Yes/No) Year Job Skills and Job interests Number of Children Who has guardianship/custody Will your children be staying with you at anytime while you re at the Exodus House? Give a brief description of your employment history: Give a brief description of your religious beliefs about God: Briefly describe what you think is your major issue and what you need to change most about yourself: Please List all medications: Briefly describe your health Projected Release Date Will you be on Probation Parole Monitor Discharge Please share anything else you d like us to know about yourself: 4

5 Authorization to Release Information (Give this to your Case Manager and send this back) Inmate Name DOC # Address Social Security Number Date of Birth This will authorize to release information from my clinical record in accordance with Oklahoma State Law Title 43 A, Section I-109. I understand that my records have a privileged and confidential status. I am waiving that status for the purpose contained within this authorization. The release of any information concerning AIDS, HIV, AIDSrelated Complex, and the performance of any tests, counseling, and the results and treatment thereof are also authorized. Specific information to be released: Consolidated Record Card (CRC CARD) This validates your charges, time you have served and any misconduct history you may have. For the specific purpose of: Assessing admission criteria and program development Information is to be released to An Exodus House Authorized Agent status are protected by Federal Regulation (42 CRF, Section 2.13) and Oklahoma Law, and that redisclosure of this information by the receiving agency is prohibited. This authorization is for a single disclosure or continuing disclosure. Valid for one hundredeighty (180) days after the date of my signature as it appears below. The client or signatory may revoke this authorization at any time upon written notification, but revocation has no effect on action previously taken. Signature of Client Date Signature of Witness Date Please return General Information Page, Authorization to Release Information Page, and your current CRC to the address on the front page. We will be contacting you soon. God Bless! 5