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Mercy Manor Application
for women with children
First & Last Name
Last known address
Phone
Birthday
*
required
Relationship Status
*
Required
Married
Single
Divorced
Widowed
Number of Dependants expected to live with you
Ages & Genders (Boys - gender by birth -allowed up to age 13)
Income
*
Required
Employed
Unemployment
Social Security/Disabiltiy
Waiting on Disability
Child Support
Do you have a proper ID to secure employment
*
Required
Yes
No
Highest Level of Education
Employer Name and Phone Number
Emergency Contact - Name
Phone Number
Have you been diagnosed with a medical condition?
*
Required
Yes
No
HEALTH
Do you have any medical issues that would prevent you from participating in household chores?
*
Required
Yes
No
What have you been diagnosed with?
Have you been diagnosed with a mental health issue or disorder?
*
Required
Yes
No
Do you have a history of suicide attempts?
*
Required
Yes
No
When was your last attempt?
Are you currently having thoughts of harming yourself?
*
Required
Yes
No
Are you seeing a doctor and/or therapist for your mental health?
*
Required
Yes
No
What medications are you on?
Name of Doctor/Therapist/Specialist or Clinic
Do you have medical or food allgergies? If yes, what is your reaction?
Do you have a Durable Power of Attorney (DPOA)? Name & phone?
LEGAL
Are you involved in the legal system in any way?
*
Required
Yes
No
Do you have to report to parole, corrections or probation?
*
Required
Yes
No
What is the name and contact information for your corrections, parole or probation officer?
What are your charges? (this is for the safety of the other families.) This will not automatically disqualify you from our program.
Are you court ordered to reside in a sober living home?
*
Required
Yes
No
Are you gang affiliated?
*
Required
Yes
No
If yes, which gang?
Do you have fines or child suppport that significantly impacts your finances?
*
Required
Yes
No
Explain current financial obligations
What are your housing needs?
HOUSING
Can you afford the $500 monthly living contribution for household costs?
*
Required
Yes
No
ADDICTION SUPPORT
How long have you been clean and sober? (include date of last known use) And what was your substance of choice?
Have you been to treatment in the past?
*
Required
Yes
No
Have you successfully completed treatment?
*
Required
Yes
No
Name(s) of treatment facilities
Are you currently in out-patient treatment?
*
Required
Yes
No
Do you go to support meetings?
*
Required
Yes
No
Do you have a sponsor?
*
Required
Yes
No
GOALS
What are your long term goals?
What are your short term goals?
Anything else you would like us to know?
Welcome to New Jerusalem Missions - Mercy Manor
Welcome to New Jerusalem Missions - Mercy Manor . We are here to help in your journey by providing spiritual, emotional and physical support. We are a non-profit Christ-centered facility and with that, our rules and guidelines reflect those of Christ. We ex
Focusing on your recovery is the number one priority. If you feel like you can not follow the rules and guidelines, take your recovery seriously, then Mercy Manor may not be the home for you.
Responsible Reporting - Mercy Manor is intended to be a stable safe environment for you to live in community with others as you continue to recover and grow. If anyone in the home is a threat to this goal, we ask that you make staff aware so the problem can be addressed immediately.
Rules & Guidelines - These are just a few basic rules. The other rules and guidelines will be discussed during your interview.
1. No Overnights out for the first 60 days. The first week after moving in, please let staff know where you are going and who you will be with.
2. Living contributions are expected to be paid in full on the first of the month, bi-weekly or weekly. Contact staff for payment arrangements.
3. Children can not be unattended. Childcare for other residents should be limited. NJM is not liable for accidents or injuries that may occur. Disciplining each other’s children is not allowed.
4. Rooms are to be kept clean and you are responsible for our own laundry. There will be weekly walkthroughs, consequences for not complying will result in, but not only, a strike and/or overnight privileges taken away.
5. Lockers are provided for you. Lock up anything you don’t want someone else to have! Staff & NJM are not responsible to replace anything that has been lost, stolen or damaged.
6. You are responsible to find your own rides to appointments, work, etc. Staff, only in emergent situations should be asked for rides.
7. We require you meet with a sponsor or spiritual advisor weekly.
8. No Pets Allowed, including emotional support animals. No visitors in the bedroom areas, no overnight guests.
9. No arguing/yelling/fighting with staff or other residents. This includes in person, on the phone or over text messaging.
Rules that are grounds for immediate discharge will be discussed during your interview.
Infractions (3 strike rule)
Breaking any of the rules under community living, although serious, is not necessarily ground for immediate discharge. Breaking a rule will put you into a behavioral contract and you will have 3 chances before we will ask you to leave our program. You will not be given 3 chances for each rule, it’s 3 chances overall.
I have read and understand these rules
Apply Now >
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