Admissions Application

Save my progress and resume later | Resume a previously saved form

Resume Later

In order to be able to resume this form later, please enter your email and choose a password.

Your Email:

A Password:

Confirm Password:

Password must contain the following:

12 Characters
1 Uppercase letter
1 Lowercase letter
1 Number
1 Special character

A. Basic Information

I am applying

For myselfFor someone else

How did you hear about the Home of Grace?

Attorney, Court or Judge	Billboard
Church	Event
Facebook, Twitter or other	Family / Friend
From Alumni	I Previously Enrolled
Internet Search	Jesus Loves Addicts Podcast
News Article	Other Program / Rehab
Print Media	Radio
TV	Valley of Grace Client
Other

Please give us more detail:

Applicant Information

If applying on behalf of someone, please only enter the contact details of the applicant. Not your own.

Sex

Male

Female

Last Four of SSN

Salutation

First Name

M.I.

Last Name

Suffix

Maiden Name

Nickname

Date of Birth

Please enter only the the CLIENT'S email and phone numbers. If the client does not have an email and/or phone, please leave blank.

Cell Phone

Home Phone

Homeless

YesNoAdult with no homestead, even if living with friend or relative.

Address Line 1

Address Line 2

City

State

Zip Code

County / Parish

Residence description:

Own or rentLiving with friends or relativesHomeless (temporary living)

Marital Status

Race / Ethnicity

Religious Denomination

Highest Level of Education

Occupation, skills or trade

NOTE: Those without a high school diploma or GED must participate in the Adult Education Program. The GED test fee is $93 plus practice testing fees.

Are you a U.S. Veteran?

Yes

Number of Children (under 18)

Have you previously enrolled in Home of Grace?

Yes

Did you graduate?

Yes

What year?

Applicant Review

Carefully review the spelling and accuracy of the applicant's information before proceeding:

Name

Date of Birth

Address

Email

Cell Phone

Home Phone

I have verified that all the information above is correct.

AgreeSee an error? Click "Previous Page"

B. Addiction History

Check ALL ADDICTIONS abused in the past FIVE YEARS:

AlcoholAmphetamine / Stimulants (Adderall, Ritalin)BarbituratesBath SaltsBenzodiazepines / Sedatives (Librium, Klonopin, Valium, Xanax)CocaineEcstasyFentanylGamblingGHB / GBLHallucinogens (Acid/LSD, PCP, Shrooms)HeroinInhalants / HuffingKratomMarijuana / THCMethamphetamineOver-the-CounterPornography / SexPrescription Opioids (Lortab, Methadone, Morphine, Oxycodone, Oxycontin, Suboxone)SpiceSteroidsTianeptine (Tianna, Zaza)Tobacco / NicotineOther Addiction

Other Addiction(s)

Select your PRIMARY addiction:

Select your SECONDARY addiction:

Do you use tobacco products?

Yes

How many packs per day?

We STRONGLY urge residents to stop using tobacco
Limited smoking and smokeless tobacco (in pouches only) are allowed in designated areas only
eCigarettes and vapors are NOT allowed
Pregnant residents or residents using inhalers are NOT allowed to smoke

Do you use vapes or eCigs?

Yes

C. Medical Information

Are you pregnant?

Yes

Maternity Information

Delivery Due Date:

No. Weeks Pregnant

No. Previous Deliveries

Any premature deliveries?

Yes

Please explain:

You will need to submit medical records, pregnancy assessment or doctor's visit documentation as well as a statement from a medical professional confirming the due date and a healthy pregnancy.
Pregnant residents must not be more than 15 weeks pregnant at intake. Pregnant residents are NOT allowed the use of tobacco products.
OUT-OF-STATE MEDICAID is NOT accepted at Mississippi Pharmacies or Medical Facilities. Therefore, prior arrangements must be made before entering the program for physician payment and pre-approved prescribed medications. Ex. Pre-natal vitamins, etc.
OBGYN Physicians DO NOT accept Out-of-State Medicaid. For maternity fees, please contact one of our local OBGYN clinics. Gulf Coast OBGYN (Pascagoula, MS): (228) 762-8136 or Mississippi Coast OBGYN (Ocean Springs, MS): (228) 872-1505.
Home of Grace staff will arrange escorted transportation to and from physician appointments when all financial arrangements have been completed.

Health History (check all that apply)

Allergies	Anxiety Attacks
Blackouts	Broken Bones
Cancer	Convulsions
Dental or Bad Teeth	Diabetes
Eating Disorder	Epilepsy
Eye Problems	Hallucinations
Handicaps	Hearing Voices
Heart Problems	Hepatitis
High Blood Pressure	HIV
Respiratory	Seizures
Severe Depression	Sleep Disorder
STD's	Suicide Attempts
Tuberculosis	Ulcers
Liver Disease	Other
None

List all other health issues

List all allergies

Hepatitis Type:

Most Recent Seizure:

Number of Suicide Attempts:

Most Recent Suicide Attempt:

Height

Weight

Recent or upcoming hospitalizations / surgeries:

List all currently prescribed medication (name, purpose, how long have you been taking?):

Will you need medication refills?

Yes

NOTE: Prior arrangements should be made BEFORE entering the program for a PRE-APPROVED 3-month supply of prescribed medication refills (ex. blood pressure medication, etc). Request local pharmacy list from Admissions for prescription transfers.

Have you ever been diagnosed with a psychiatric or mental disorder?

Yes

Please describe:

Do you have any handicaps or physical limitations?

Yes

Describe

Have you ever been in treatment for substance abuse?

Yes

How many times?

Who is responsible to pay your medical expenses?

Do you have health insurance?

Yes

Insurance Provider

Other Insurance Provider Name

PLEASE NOTE

PROHIBITED MEDICATIONS include (but are not limited to) barbiturates, narcotics, opiate blockers, sleep-aids, and mood altering drugs.
ALL MEDICATIONS (prescribed and over-the-counter) must be PRE-APPROVED prior to intake and turned in upon arrival.
DETOXIFICATION: Resident must be physically detoxed and able to participate in required daily activities prior to enrollment. The Home of Grace is NOT a medical facility and CAN NOT provide medically supervised detox. Contact your local hospital for a list of detox facilities.
All travel arrangements, medical appointments, dental appointments, chiropractic care, vision appointments, and surgeries should be scheduled AFTER the program completion date.

Detoxification

I understand that I (applicant) must be safely detoxed before intake, otherwise, I (applicant) will not be admitted.

I AGREE

Enter Initials

Medical Policy

I understand that misrepresentation of my (applicant's) medical condition will result in dismissal with no refund. I affirm that all information submitted is complete and accurate.

I AGREE

Enter Initials

D. Emergency Contacts

Contact #1

Salutation

First Name

M.I.

Last Name

Suffix

Relation to Applicant:

Relationship details

Same address as applicant:

Yes

Cell Phone

Home Phone

Work Phone

Fax

Address Line 1

Address Line 2

City

State

Zip Code

Do you have a second emergency contact?

Yes

Contact #2

Salutation

First Name

M.I.

Last Name

Suffix

Relation to Applicant:

Relationship details

Cell Phone

Home Phone

Work Phone

Fax

Same address as applicant:

Yes

Address Line 1

Address Line 2

City

State

Zip Code

E. Legal Evaluation

Do you have (or anticipate) any pending legal obligations?

Yes

Such as DHS, OCS, Family Court, Civil, etc.

Will you be under court order while enrolled?

Yes

NOTE: Court order MUST be provided at check-in

Do you have court dates pending?

Yes

Court Date 1

Court Date

Court Name

Judge Name

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Fax

Add another court date

Court Date 2

Court Date

Court Name

Judge Name

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Fax

Add another court date

Court Date 3

Court Date

Court Name

Judge Name

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Fax

If you have more than 3 court dates, please let your admissions counselor know.

Do you have an attorney?

Yes

Attorney Information

First Name

Last Name

Cell Phone

Home Phone

Work Phone

Fax

Address Line 1

Address Line 2

City

State

Zip Code

Are you under probation / parole?

Yes

Probation/Parole Officer Information

First Name

Last Name

Cell Phone

Home Phone

Work Phone

Fax

Address Line 1

Address Line 2

City

State

Zip Code

Have you ever pled guilty or been convicted of a crime?

Yes

List any felonies, misdemeanors or pending charges:

Are you applying from jail?

Yes

Where?

NOTE: It is the responsibility of the resident to have ALL appointments postponed (legal, medical, personal, etc) until completion of the three month program.

F. Final Agreements

Postpone Obligations

I understand that I (applicant) am responsible to postpone ALL appointments (legal, medical, personal, etc) until the completion of the three-month program.

I AGREE

Enter Initials

Intake Reschedule Policy

I understand that I (applicant) am responsible to arrive no later than my appointed intake time, and a postponement for any reason will require a non-refundable deposit of $500 before another intake can be rescheduled.

I AGREE

Enter Initials

No Refund Policy

I understand that NO REFUND of any amount will be offered under any circumstance.

I AGREE

Enter Initials

Statement of Faith

I have read and understand the Home of Grace's Statement of Faith.

I AGREE

Enter Initials

Save my progress and resume later | Resume a previously saved form