RESIDENT APPLICATION CHECKLIST: 1) Review, sign and initial every page of this application where applicable. 2) Make sure to sign the Background Check Authorization form – it is the first thing we must submit before proceeding with intake. You may not have any sexual charges or violent felony battery charges, or more than one (1) misdemeanor battery charge. 3) Write a detailed Personal History at the bottom of the application telling us about yourself, your history, and why you want to come to Good Shepherd Recovery House. 4) You must be interviewed by the Executive Director and/or Program Director in person, or by phone or video. 5) You will be required to show some form of identification upon entrance. You will be responsible for the following fees in order to enter the program: 6) $35 Intake Fee for Background Check (due at time of submission of application) 8) $500 Intake Fee (due after application approved; required to receive an Acceptance Letter) 9) $1000 1st Month Program Fees 10) $100 for Medical Testing upon Intake, which includes a Nurse Exam, TB and RPR (Syphilis) Test (required by the State), as well as testing for HIV, Hep A B C. Testing is solely to ensure that anyone with a transmittable disease receives the medical treatment and medications they require, and if necessary, they will be quarantined in the house until they are no longer contagious. No one may go into the kitchen until these tests results have been returned. If you have any questions, please feel free to call Intake Coordinator at 678-459-2347 or the Program Director at 678-459-2346 x 103, or email info@gsrecovery.org.

I understand that Good Shepherd Recovery House will utilize the services of Horizon Background Screening, 12460 Crabapple Rd, Suite 202-271, Alpharetta, GA 30004-6386 (the “Agency), to obtain a consumer report and/or investigative consumer report (“Report”) as part of its review of my application for service as an employee, volunteer, or other association. I also understand that if accepted, to the extent permitted by law, the organization may obtain further Reports throughout my employment or volunteer service from a consumer reporting agency. I understand the Agency’s investigation may include obtaining information regarding my credit background, bankruptcies, lawsuits, judgments, paid tax liens, unlawful detainer actions, failure to pay spousal or child support, accounts placed for collection, character, general reputation, personal characteristics and standard of living, driving record and criminal record, subject to any limitations imposed by applicable federal and state law. I understand such information may be obtained through direct or indirect contact with former employers, schools, financial institutions, landlords and public agencies or other persons who may have such knowledge. If an investigative consumer report is being requested, I understand such information may be obtained through any means, including but not limited to personal interviews with my acquaintances and/or associates or with others whom I am acquainted. I acknowledge receipt of the attached summary of my rights under the Fair Credit Reporting Act and, as required by law, any related state summary of rights (collectively “Summaries of Rights”). This consent will not affect my ability to question or dispute the accuracy of any information contained in a Report. I understand if the Employer makes a conditional decision to disqualify me based all or in part on my Report, I will be provided with a copy of the Report and another copy of the Summaries of Rights, and if I disagree with the accuracy of the purported disqualifying information in the Report, I must notify the Employer within five business days of my receipt of the Report that I am challenging the accuracy of such information with the Employer. I hereby consent to this investigation and authorize the Company to procure a consumer report and investigative consumer report on my background as stated above from a consumer reporting agency and/or investigative consumer reporting agency.

RPM Ministries, Inc is the parent ministry of Good Shepherd Recovery House (GSRH). All information, rules and guidelines set forth in these documents are to be applied to and adhered to by Good Shepherd Recovery House, and any other ministry that may operate under the covering of RPM Ministries, Inc.

In this section, please complete all sections that apply to you. Enter N/A for sections that do not apply to you.

Benzodiazapines, Narcotics, and other mood altering or sleep inducing medications are not allowed in this ministry. Many other drugs are not allowed due to causing false positives on drug tests. Medication Assisted Treatment drugs are not allowed in this program. APPROVED MEDICATION LIST Allergy · Claritin or generic equivalent (may NOT contain pseudoephedrine) Cold and Flu · Acetaminophen or Ibuprofen · Saline nasal drops or spray · Warm salt/water gargle · Cough Drops or Throat Lozenges Constipation · Colace · Metamucil First Aid Ointment · Bacitracin · Neosporin or generic equivalent Rashes · Caladryl lotion or cream · Hydrocortisone cream or ointment. ADDITIONAL MEDICATIONS Prescription medications such as antibiotics and antidepressants are generally acceptable but MUST be cleared with staff at the time of admission. Other medications used to manage cravings such as Naltrexone, Suboxone, Campral or Antabuse are on a case-by-case basis and MUST be cleared with staff at time of admission. Nicotine patches or gum may be purchased by the client and self-administered under Staff supervision as with all other approved medications, but for no more than four (4) weeks. NON APPROVED · ANY medication containing pseudoephedrine, diphenhydramine or dextromethorphan contained in brands such as Sudafed, Dayquil, Theraflu, Benadryl, Robitussin DM or any other "DM" cough syrup · ANY prescription opiates of any kind such as in Tylenol #3, Percocet, Vicodin, Darvocet, Lortab, etc. · ANY benzodiazepine including Ativan, Xanax, Klonopin, Valium · ANY stimulant such as diet pills (including herbal remedies) or ADHD medications such as Adderall, Ritalin, Concerta, phentermine · ANY sleep agents including Tylenol PM, Advil PM, Ambien, Lunesta, Sonata. THIS INCLUDES THE USE OF BENADRYL. (Melatonin is a safe alternative.) · ANY preparations that have an alcohol base such as mouthwash and cough syrup. · ANY steroids not prescribed by a doctor. **IF YOU ARE UNCLEAR ABOUT ANY MEDICATION, ASK BEFORE YOU TAKE IT**

Please answer with specific information. Include contact information for probation and parole officers. Include every charge and conviction. If you have never been charged with an offense, you can enter N/A.

Please be specific about your work history, jobs held, skills learned and level of skill.

Please be specific in the names of the substances you have taken, as well as the methods of use, and how long you have used each substance.

I understand that I am under your care and direction while I am in this program and reside at this facility. I agree and will comply by all of the rules and regulations as listed.

$ 35.00 Background Check Fee (NON-REFUNDABLE) $ 1,000.00 Basic Recovery Program (1 monthly communication with Supervising Officer). Includes bed, food, Recovery Program supplies, counseling, transportation to group events. Does NOT include specialty foods, individual transportation to appointments, etc. ALL FEES ARE NON-REFUNDABLE. Payments must be RECEIVED by the LAST BUSINESS day of the month for the next month’s Program. (October payment is due on the last business day of September.) The following fees are NON-REFUNDABLE $ 500.00 Intake Fee. NON-REFUNDABLE. $ 100.00 Medical Exam and Testing Fee NON-REFUNDABLE $ 10.00 Per each TYPE (EtG, 12 Panel, Nicotine, Synthetic, etc.) of Drug Test (if more than once per month is required). If Staff suspects drug use and the client is clean, GSRH will pay for the tests. Otherwise, the client will pay for any required additional tests. NON-REFUNDABLE $ 40.00 Per hair follicle drug test if required more than three times per year. NON-REFUNDABLE Calculation Transportation charges ‐ $0.585 per mile with standard gas prices b elow $4.00 per gallon. As fuel prices increase, so will the per mile p rice for transportation. NON-REFUNDABLE Value Replacement value of any item broken by client. NON-REFUNDABLE. If a Resident starts his stay after the first of the month, there will be a prorated fee for his 2nd month. But all clients must pay for their first full month. All monies are due in our office or deposited to our account no later than noon on the last business day prior to the 1st day of the month. Sponsors are responsible for all payments throughout the 12+ month program. If the Resident is able to procure a job after Phase 1 (by the 4th month), his income can be applied toward his fees for the 5th month and thereafter. If the Resident is unable to pay for any portion of his program, the Sponsor is responsible for paying the remaining fees due. If for any reason the client leaves (failed drug test, violence, of their own choice, of their family’s choice, etc.) there will be no refund on any monies paid to this Ministry and balance of tuition becomes due immediately. Sponsor ___________________ Date __________ Staff ______________________ Date __________ I understand and agree to the above-referenced fees.

***READ THIS SECTION CAREFULLY. DO NOT SIGN until you KNOW what will be REQUIRED of you, and what will NOT be allowed. ***************** This is a condensed summary of additional documentation you will be required to sign during your orientation. We are a non-smoking, Christian 12+ month State Licensed and THOR Approved Drug and Alcohol Treatment and Education Program. Our curriculum requires Christian devotions, discipleship classes, 12-Step program and church. Much of our curriculum mentions scripture. You do not need to be a Christian or believe what we believe. However, you are expected to complete the curriculum, participate in discussions, and treat our beliefs with respect. You may use nicorette gum or patches to stop smoking over your first 4 weeks. We provide 1 written warning for breaking a rule. From thereon out, you receive Write ups and their consequences 1st write up: Black out weekend - no phone, visitation or work, 2nd write up: Black out weekend and 1 written assignment 3rd write up: Black out weekend, 2nd written assignment, 1 week added to your graduation, and you are placed on a 30 day probation. 4th write up in a month and you are dismissed from the program. On Wednesdays, you must attend five (5) hours of group counseling from 8 am to 1 pm, so you cannot work on Wednesday mornings. You can work on Saturday, though. You cannot work outside of the House for a minimum of three (3) months, so you must be able to pay for your program and additional fees out of your own monies, or have a sponsor who will pay for your first 4 months plus intake fee. You can start working in the 4th month and begin paying for your program fees in the 5th month. You may not work 2nd or 3rd shift. Your first thirty (30) days are Blackout - no contact with family or friends except by written letters. You are on probation for those first 30 days. If you cannot get along with the other men or cannot follow the rules and guidelines, you will be released from our program. Visitation is every Saturday and Sunday afternoon. Visitation must be submitted and approved by the previous Wednesday. Passes begin in your 4th month. First 12 hour day passes every other week. Then overnight pass every other week. Then 2 night pass every other week. Passes must be submitted and approved on Wednesdays prior to the pass. We expect you to be as serious about your recovery as we are. Romance and recovery DO NOT mix, no new relationships with the opposite sex, not even friends. If you were not in an active relationship when you entered the program, you will not be able to have contact with that female. DO NOT continually ask for special favors, learn to adjust to your new environment You are responsible for your own mental and physical condition, we are not a facility specializing in that type of care. We will help you set up medical appointments and take you to them and to pick up medicine, but you are responsible for paying for your visits and medications. You assume all risks relevant to your stay here, you promise to follow all rules and regulations, and you will not sue GSRH for any matter that will arise during or because of your stay here You must return to GSRH every night unless on pass All mail will be opened Any items left after 3 days will be disposed of as GSRH sees fit Family/sponsor agreement: you will follow and uphold all GSRH decisions and cooperate with us fully 5 Big Areas: Tobacco, violence, pornography, alcohol, drugs - any infractions in these areas, on or off site, can get you dismissed immediately Cost of the program: $500 intake, $1000 monthly includes room, food, counseling, curriculum. Additional fees are stated in the attached Fee Page. The client or their sponsor is responsible to make payments by the last business day of the month before the new program month begins. There are no refunds for any reason and any monies owed are due immediately You will need to release Confidential info to your supervising officer, if you have one. You will provide authorization for us to receive medical information about you. You will provide an Approved contact list You break it you buy it; you run the bill up, you pay for it; if you see something wrong, say something about it We can search you, your room, your property and your vehicle at any time on any of our properties If you relapse and are honest, we can work with you; if you lie about it, you will be dismissed. Everything you see and hear regarding anyone in the program is confidential. There is a limited Approved medication list. No narcotics, no mood or sleep medicines unless REQUIRED by a doctor for health reasons. Liability and accident waiver; you assume all risks for yourself and cannot sue us If you feel you have been in any way sexually harassed or abused, you must report it immediately When you earn the privilege to work, all of your paychecks are delivered to Good Shepherd Recovery House for deposit into a joint Client bank account from which you can retrieve $20 per week in pocket money, and additional approved monies for gas, food, etc. If you have a grievance, fill out a form and submit it for investigation and resolution.

Items allowed for intake The following items are total number allowed for each item, you do not have to have this many but not more than what is listed below. 10 outfits (which includes church and work clothes combined) 2 Pajamas 4 pairs of shoes 10 pair socks and under clothes 2 jackets 2 Pillows Personal items *Alarm Clock *Razors *Soap *Shampoo and Conditioner *Deodorant *Toothpaste & Toothbrush *Bible Paper & Pen Stamps & Envelopes Christian music, magazines and books Note: Certain type Razors have to be approved by staff Residents are NOT to share or give their personal items to others for any reason. If emergency arises GSRH will meet those needs. In His Great Love, Pastor/Director Ronnie Haynes

Good Shepherd Recovery House 601 Moore Rd. Jasper Ga. 30143 678-459-2346 Good Shepherd Recovery House CONSENT FOR THE RELEASE OF MEDICAL INFORMATION I authorize Good Shepherd Recovery House to acquire all medical records. The purpose of the authorization in this consent is to: Continue existing medical care and provide information for pre-existing conditions. I understand that I may revoke this consent at any time except to the extent that action has been taken in reliance on it, and that in any event this consent expires automatically as follows: 90 days after completion or exiting program. I understand that I might be denied services if I refuse to consent to a disclosure for purposes of treatment, payment, or health care operations, if permitted by state law. I will not be denied services if I refuse to consent to a disclosure for other purposes. I have been provided a copy of this form.

Please use the below box to tell us your personal history. Tell us about your life including: growing up, your family members and significant others, any trauma you have experienced, your substance use history, why you want to come to Good Shepherd Recovery House.

***NOTE: We cannot process your Application without payment for your Background Check.*** For Zelle, use info@gsrecovery.org For Checks - make it out to Good Shepherd Recovery House Mail it to: Good Shepherd Recovery House PO Box 328 Holly Springs, GA 30142-0006