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Restoration Place Application
First & Last Name
Last known address
Phone
Birthday
*
required
Income
*
Required
Employed
Unemployment
Social Security/Disabiltiy
Waiting on Disability
Email (optional)
Relationship Status
*
Required
Married
Single
Divorced
Widowed
Number of Dependants
Do you have a proper ID to secure employment
*
Required
Yes
No
Employer Name and Phone Number
Emergency Contact - Name
Phone Number
Highest Level of Education
Have you been diagnosed with a medical condition?
*
Required
Yes
No
HEALTH
What medications are you on?
What have you been diagnosed with?
Is there anything that would prevent you from helping with chores?
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 for your mental health?
*
Required
Yes
No
Do you have a therapist you are seeing?
*
Required
Yes
No
Name of Doctor or Clinic
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?
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
HOUSING
What are your housing needs?
Can you afford the $400 monthly living contribution? (rent)
*
Required
Yes
No
What is the reason for your housing need?
ADDICTION SUPPORT
How long have you been clean and sober? (include date of last known use)
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
Do you go to support meetings?
*
Required
Yes
No
Do you have a sponsor?
*
Required
Yes
No
Are you currently in out-patient treatment?
*
Required
Yes
No
GOALS
What are your long term goals?
What are your short term goals?
Welcome to New Jerusalem Missions - Restoration Place . 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.
Rules & Guidlines- These are just a few basic rules. The other rules and guidelines will be discussed during your interview.
1. The first 60 days after moving in, you will not be allowed to have any nights out. After that, requests should be at least 3 days prior. You will also need to have your monthly living contribution paid.
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. No arguing/yelling/fighting with staff or other residents. If you have conflict with another resident, please speak to them. If not able to resolve it then bring it to staff.
4. Rooms are to be kept clean and you are responsible for our own laundry. No food is permitted in your bedrooms.
5. No Pets Allowed, including emotional support animals. No visitors in the bedroom areas, no overnight guests.
6. No smoking in the stairwell, smoking area is at the top of the stairs to the left. No tobacco use inside, no vaping inside. Vape in designated smoking area.
7. Lockers are provided for you. Lock up anything you don’t want someone else to have!
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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