Potential Client Application

First Name:

Middle Name:

Last Name:

Phone Number:

Permanent Address:

Mailing Address:

Date of Birth:

Age:

Social Security Number:

Email:

Gender:

Race:

Veteran:

How did you hear about Freedom Hill:

Emergency Contact Information:

You must submit TWO emergency contacts.

Emergency Conact #1 First and Last Name:

Emergency Contact #1 Relationship:

Emergency Contact #1 Address:

Emergency Contact #1 Phone Number:

Emergency Contact #1 Email:

Emergency Contact #2 First and Last Name:

Emergency Contact #2 Relationship:

Emergency Contact #2 Address:

Emergency Contact #2 Phone Number:

Emergency Contact #2 Email:

Medical Health:

This next section covers medical (physical, dental, etc) health. Menal health will be addressed in the next section.

Are you currently under a doctor's care?:

If YES, list the Dr's name and number::

Doctor's Address:

Date and Reason for last visit::

List ALL medications you are taking for MEDICAL issues:

List ALL allergies, medical, physical, and dental issues:

Mental Health:

This section is specifically regarding your mental health situation,

Are you currently under a doctor's care?:

Doctor's Name/ Phone Number:

Doctor's Address:

Date and Reason for last visit::

List ALL medications you are taking for MENTAL HEALTH issues:

List allergies/ mental health problems/ behavioral or emotional issues:

Family Social:

This section is regarding family/ children.

Do you have children?:

Ages/ Gender of Children (ex 5 yr Male):

What are the children's current living arrangements?:

Are these arrangements set up through the court?:

Do you have pending/ open DFCS cases?:

If YES, please explain::

DFCS Caseworker Name/Number/Email:

Marital Status:

If ENGAGED: Fiance's Name/ Phone Number/ Length of Relationship:

If LEGALLY MARRIED: Spouse Name/ Number/ Length of Relationship:

If SEPERATED or DIVORCED: How long has the separation/ divorce been?:

List Individuals you consider your support system: NAME/ NUMBER/ ADDRESS/ RELATIONSHIP:

Legal:

This section pertains to your current/ past legal situation.

Are you currently on Probation or Parole?:

If so, list Officer's Name/ Phone Number and Email:

Do you have legal representation?:

If so, list Name/ Number/ Email:

Do you have any warrants?:

Do you have any pending cases? (including but not limited to disability, DFCS, etc):

If so, please explain::

Do you have any violent convictions?:

Do you have any sex offense convictions?:

Release of Information:

Freedom Hill is prohibited from discussing your status, including acknowledgement of you as a individual, with anyone without your written permission. Please complete the following Releases of Information as it pertains to your situation.

A. In the event that you are incarcerated or in some type of controlled environment with limited communication (i.e. Hospital) , is there someone we can discuss your application status with regarding acceptance, admission, financial, etc?:

B. Is there someone that will be financially supporting you during treatment, indcluding but not limited to, your monthly tuition?:

If so::

An email will be sent to the email address you provided to complete a Release of Information. In addition, if you answered YES to questions regarding medical, mental, DFCS, or Legal (I.e. probation or attorney), You MUST complete the release. When the release is sent, please print it, fill it out, then scan it back to admin@freedomhillhome.com. Failure to complete will prohibit Freedom Hill from discussing your status with individuals listed above. Please complete a separate Release of Information for each individual you have listed. If you need assistance, please use the email above to get help.

Please Read:

Insurance is not provided for accident, injury, or illness on the premises. I understand that I am responsible for any medical bills I, or any member of my family, incur or damage I, or any member of my family cause while at Freedom Hill. I hereby assume any risks that may be incident to my stay at Freedom Hill, and agree that neither I nor any of my heirs or assigns will hold Freedom Hill responsible for any damagers that occur during my stay at Freedom Hill and I hereby release and relinquish for any and all claims of any nature whatsoever that might arise out of my star at Freedom Hill 210 Loudermilk Ln, Demorest, Ga 30535. I also understand that Freedom Hill is a Christian Ministry and that my ministry that I receive is based on staff's understanding of Christian principles and the Bible.

Applicant Signature:

Clear

Date:

Witness Signature:

Clear

Background Consent:

Please give Freedom Hill the necessary information and authorization to complete an in-house background check as part of the admission process.

Signature:

Clear

Date:

Driver License Number:

Any Additional Address(es) Within the last seven years:

Please enter email to receive copy of submitted report

Freedom Hill Recovery Home for Women

Potential Client Application