Emergency Contact Information

Referral Source Information

If you're coming from a Hospital, Prison, Jail, Rehab, you must have the following when you arrive:

1. One month supply of medications

2. If diagnosed with a mental illness, you need to have a follow-up appointment at a local mental health office

3. No Narcotic Pain Medications or Controlled Substances (Lortabs, Xanax, Benzos, Suboxone, etc)

4. Approved Psych Meds are allowed

Applicant Health Information

Alcohol and Substance Abuse Information

If you can't pass a drug/alcohol screen when you arrive at the mission, you will still be allowed to stay but you can't leave our facility until you can pass one. If you are dishonest about your drug/alcohol usage on your application you won't be allowed to stay at intake time.

Answer "NA" if this doesn't apply to you.

Applicant Court, Parole, Probation Status and Information

Answer "NA" if you don't have a criminal history.

Applicant Previous Residency Information