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New Jerusalem Missions
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Restoration Place Application
Full Name
Last known address
Phone
Birthday
Income
Employed
Unemployment
Social Security/Disabiltiy
Waiting on Disability
Email (optional)
Relationship Status
Married
Single
Divorced
Widowed
Number of Dependants
Do you have a proper ID to secure employment
Yes
No
Employer Name and Phone Number
Emergency Contact - Name
Phone Number
Highest Level of Education
Have you been diagnosed with a medical condition?
Yes
No
HEALTH
What medications are you on?
What have you been diagnosed with?
Is there anything that would prevent you from helping with chores?
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 for your mental health?
Yes
No
Do you have a therapist you are seeing?
Yes
No
Name of Doctor or Clinic
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 gang affiliated?
Yes
No
If yes, which gang?
Do you have fines or child suppport that significantly impacts your finances?
Yes
No
HOUSING
What are your housing needs?
Can you afford the $375 monthly rent amount?
Yes
No
What is the reason for your housing need?
ADDICTION SUPPORT
How long have you been clean and sober? (include date of last known use)
What was your substance of choice?
Have you been to treatment in the past?
Yes
No
Have you successfully completed treatment?
Yes
No
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?
Welcome to New Jerusalem Missions
We are here to help in your journey. To help you succeed and to help you live in community we have a few rules. Be kind, understand everyone has their own battles. We are to fight for each other, not against each other. The TV is communal, please share who picks what’s on and keep the volume at a reasonable level. We are a Christian facility, be careful what you watch and the games you play.
1. 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.
2. Quiet hours are from 10 p.m. - 7 a.m.
3. No smoking in the stairwell, smoking area is at the top of the stairs to the left. No tobacco use inside, no vaping inside. Vape in designated smoking area.
4. Rent is due at the first of the month and will be considered late after the 10th. Payment arrangements can be made if needed. You will be given a financial contract if you fall behind more than 2 months on rent.
5. Curfew is 8 p.m. Sunday - Thursday and 10 p.m. on Friday & Saturday. If you are going to miss curfew due to work or AA/NA/CR you need to let the RA or Staff know before you go.
6. No Pets Allowed, including emotional support animals. No visitors in the bedroom areas, no overnight guests.
7. No arguing 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.
8. Rooms are to be kept clean and you are responsible for our own laundry. Wash you sheets weekly.
The Rules-
9. No Refrigerators in your bedroom.
Rules that are grounds for immediate discharge
1. Being under the influence of any drugs not prescribed to you by a physician, alcohol or any illicit substances
2. Possession of alcohol, illegal drugs, drugs not prescribed to you
3. Possession of any weapon, including gun, knives (without permission)
4. Physical violence or threats of violence to staff or other residents
5. Failure to submit to UA or breath test when requested by staff
6. Lying
7. Stealing from other residents, staff or the mission
8. Any criminal activity
9. Possession or use of pornography
10. Destruction or damage to other resident’s property, staff property the Mission building, facilities, etc.
Infractions and House Restriction
Breaking any of the rules under community living, although serious, is not necessarily ground for immediate discharge. Consequences will be decided on a case by case basis. Braking 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. Any infractions, arguing with staff, endangering others sobriety will result in immediat removal.
I have read and understand these rules
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