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Grace Place Application
For Women
Full Name
Last known address
Phone
Birthday
Relationship Status
Married
Single
Divorced
Widowed
Income
Employed
Unemployment
Social Security/Disabiltiy
Waiting on Disability
Do you have a proper ID to secure employment
Yes
No
Highest Level of Education
Employer Name and Phone Number
Emergency Contact - Name
Phone Number
Have you been diagnosed with a medical condition?
Yes
No
HEALTH
Do you have any medical issues that would prevent you from participating in household chores?
Yes
No
What have you been diagnosed with?
Have you been diagnosed with a mental health issue or disorder?
Yes
No
Do you have a history of suicide attempts?
Yes
No
When was your last attempt?
Are you currently having thoughts of harming yourself?
Yes
No
Are you seeing a doctor and/or therapist for your mental health?
Yes
No
What medications are you on?
Name of Doctor/Therapist/Specialist or Clinic
Do you have medical or food allgergies? If yes, what is your reaction?
Do you have a Durable Power of Attorney (DPOA)? Name & phone?
LEGAL
Are you involved in the legal system in any way?
Yes
No
Do you have to report to parole, corrections or probation?
Yes
No
What is the name and contact information for your corrections, parole or probation officer?
Are you court ordered to reside in a sober living home?
Yes
No
Are you gang affiliated?
Yes
No
If yes, which gang?
Do you have fines or child suppport that significantly impacts your finances?
Yes
No
Explain current financial obligations
What are your housing needs?
HOUSING
ADDICTION SUPPORT
How long have you been clean and sober? (include date of last known use)
Have you been to treatment in the past?
Yes
No
Have you successfully completed treatment?
Yes
No
Can you afford the $375 monthly living contribution?
Yes
No
What was your substance of choice?
Do you go to support meetings?
Yes
No
Do you have a sponsor?
Yes
No
Are you currently in out-patient treatment?
Yes
No
GOALS
What are your long term goals?
What are your short term goals?
Anything else you would like us to know?
Welcome to New Jerusalem Missions - Grace Place
We are here to help in your journey. In order to help you succeed and help you live in community we have a few rules.
The Rules-
1. The first 2 weeks after moving in, you will not be allowed to have any nights out. After that, requests should be at least 3 days prior.
2. Curfew is 8 p.m. Sunday - Thursday and 10 p.m. on Friday & Saturday. Individual choice of bedtimes will vary, please keep this in mind.
3. Quiet hours are from 10 p.m. - 7 a.m. Please be respectful of others trying to sleep. Those who work overnights need to sleep during the daytime.
4. If you are going to miss curfew due to work or AA/NA/CR you need to let Zoe know before you go.
5. Monthly Living contributions are due at the first of the month. Payment arrangements can be made if needed. Speak to Kerri about making arrangements. You will be given a financial contract if you fall behind more than 2 months on your contributions.
6. No TV's in your bedroom. This is a community living space
7. Do your chore, it changes weekly. You are responsible for checking when it changes, if you have any questions on your chore please talk to the staff. It is not your job to remind others of their chores.
8. No arguing/yelling/fighting with staff or other residents. If you have conflict with another resident, please speak to them. If not able to resolve it then bring it to staff.
9. Smoking and vaping in the backyard, only in designated areas.
10. No Pets Allowed, including emotional support animals. No visitors in the bedroom areas, no overnight guests.
11. Rooms are to be kept clean and you are responsible for our own laundry. There will be weekly walk throughs. Make sure you area is picked up and clean or you could lose your privilege of nights out.
12. No Refrigerators in your bedroom. No food is permitted in your bedrooms.
13. Lockers are provided for you. Lock up anything you don’t want someone else to have!
14. We will have required weekly house meetings each Sunday, times will vary.
Rules that are grounds for immediate discharge-
1- Not meeting financial obligations in a timely manner. 2 - Destruction or damage to other resident’s property, staff property the Mission building, facilities, etc. 3 -Being under the influence of any drugs not prescribed to you by a physician, alcohol or any illicit substances. Possession of alcohol, illegal drugs, drugs not prescribed to you
4 - If relapse occurs and you hope to re-enter our sober living home, you will be expected to go to detox. 5- Possession of any weapon, including gun, knives (without permission) 6- Physical violence or threats of violence to staff or other residents 7-Failure to submit to UA or breath test when requested by staff.
8 -Faking or attempting to fake a UA 9 -Lying 10 -Stealing from other residents staff or the mission. 11 - Any criminal activity 12- Possession or use of pornography.
Infractions and House Restriction
Breaking any of the rules under community living, although serious, is not necessarily ground for immediate discharge. Breaking a rule will put you into a behavioral contract and you will have 3 chances before we will ask you to leave our program. You will not be given 3 chances for each rule, it’s 3 chances overall.
House Restriction is the most severe penalty. It is usually the last opportunity for a resident to keep from being removed. This means the resident will only leave the house with permission. The resident must give an account for any time they are permitted to leave the house. Valid reasons are work, AA/NA/CR meetings and medical appointments. Any unpermitted activity will resul
I have read and understand these rules
Apply Now >
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