Admissions Application (revised September 2019)

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A. Basic Information




Applicant Information

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













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













NOTE: Those without a high school diploma or GED must participate in the Adult Education Program. The GED test fee is $90 plus practice testing fees.





Applicant Review


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







See an error? Click "Previous Page"

B. Addiction History







  • 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

C. Medical Information


Maternity Information





  • 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.












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.









PLEASE NOTE
  • You must submit TB test results and proof of HIV testing prior to intake.
  • PROHIBITED MEDICATIONS include (but are not limited to) antidepressants, 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.
Detoxification

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

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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.

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D. Emergency Contacts

Contact #1


















Contact #2

















E. Legal Evaluation


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

NOTE: Court order MUST be provided at check-in

Court Date 1










Court Date 2










Court Date 3










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

Attorney Information













Probation/Parole Officer Information

















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.

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Program Fee

I understand the program fee is firmly set at $3,000 for the three-month residential program and must be paid in full at the time of intake.

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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.

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No Refund Policy

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

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Need help? Call (228) 826-5283 or email us.

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