Pre Intake Application Date: _________________
We are a faith-based recovery program based on 3 phases with a 9-month term.
There is an initial 14/ day probationary period that is an assessment if you a right fit for our program followed
by a 90 day probationary period for a final review of your acceptance into our program
We are a work therapy training program. We work six days a week from 8:00- 4:30
Upon intake, everyone will be drug tested with additional random testing during their stay in the program.
There will be no outside contact with anyone for the first 90 days of the program. Once the probation period is
complete residents will be eligible for visits and phone calls. ( Please refer to our visitation policy.)
Once our residents reach the 211th day of the program they will be eligible to seek a full-time job as well as the
opportunity to obtain a cell phone.
You are allowed to bring 2 bags of personal clothes upon intake.
Full Name: _______________________________________________________________
Phone # ____________________________ D.O.B: _____________________________
Where are you calling from? _________________________________________________
Where did you sleep last night? ______________________________________________
Past Employment: _________________________________________________________
Do you have a driver's license? __________
Do you have your Birth Certificate? _________
Do you have your Social Security Card? _________
Do you have your food stamp card? _________
Do you have your High School diploma? ______________ College? _____________
Were you in the military?
Are you on disability? ______________________________________________________
Do you have any physical limitations that would keep you from participating in our program?
Are you on any medications:___________________________________________________
What are they? _____________________________________________________________
How long have you been taking them? __________________________________________
Last time you used?:_________________________________________________________
Last time you drank?:________________________________________________________
Detox Needed: Y / N
Active Warrants Y / N
Ever been charged with Domestic Violence: Y / N
Probation: Y / N Misd. / Felony PO:_____________________________________________
Dates:____________________________ States:_____________________ Counties:____________
Registered Sex Offender: Y / N
Marital status: S / M / D / Sep / W Other Relationships:_______________________________
Spouse / Significant other in need of shelter also: Y / N
Children under 18: Y / N With them: Y / N To join later: Y / N
Age of Children and are they Boys or Girls ______________________________________________
So, tell me what has happened in your life that has brought you to become homeless? Why do you want to come to our program?
Previous programs:_________________________date of entry:_________
Previous experience with Christianity/ God/Religion?________________________________________________________________
Resident Program Policy Guide
Welcome to Sanctuary Mission and Grace House. We are excited to help you begin your Journey of Recovery with our life recovery program.
This is a faith-based program. Our residents have daily bible study, attend church every Sunday and Wednesday, and participate in the 12-step program. Our program also uses tools like counseling, mentorship, and work therapy to help you find your way back to a meaningful and fulfilling life. We pray that you will allow God to work in your life to find true and permanent change.
The Journey of Recovery program is a 274-day program. There are three phases to our program. When you have completed the third phase, you will have completed our program!
An important tool in your journey to recovery is financial accountability. Here at Sanctuary Mission and Grace House, we have an Upstanding Of Financial Accountability memorandum (referred to as the UFA). The UFA is designed to establish a successful progression of financial accountability for positioning the resident toward completing and transitioning out of the program.
Complete Intake Process:
Application, Financial Accountability, emergency and key family contacts, background check, and verifications. Overall Needs Assessment:
The case manager/ will do an assessment interview with guests to identify necessities, i.e., Driver's License, Social Security Card, Birth Certificate, Clothing, hygiene, first aid, mental health, etc.
Phase 1: 1-90 Days
2 Week & 90 day Review — Progress Interview by Program Manager
This staff interview is to determine the guest's progress in entering the long-term program. The guest will either enter the Program or exit.
1-90-day probation Period
This period is for the resident to acclimate themselves to a personal recovery mindset. You will not earn any income in this probationary period.
After completing 90 days, you will be eligible for on-campus visits with a written request and work-for-hire income. (See Visitation Policy)
Various topics of recovery and life skills training.
Assigned work program and job readiness training.
Case Management (checklist):
Working with residents to resolve life-hindering issues, court fees, DL, SS, GED, etc.
Please read our Understanding of Financial Accountability (UFA) memorandum.
Phase 2: 91-210 Days
The case manager and resident work together on a case plan for recovery needs.
Phase 2 Benefits: Our residents will be eligible for off-campus visitation for up to 8 hours. (See Visitation Policy)
Phase 3: 211 – 274 Days
The resident will continue to do work for hire while pursuing full-time employment. Once a resident obtains employment, the resident must give a two-week notice to the work-for-hire program.
The resident will begin to search for a sponsor/mentor for continued spiritual development and personal accountability.
Continued as needed. Refer to the checklist.
No visits during your first 90 days.
All visits are on Sundays after church. The resident will be back on campus no later than 8 pm.
Phase One (1-90 days) Residents are not eligible for on-campus visits . Phone calls after 45 days
Phase Two (91-210 days) Residents are eligible for two 4 hours on-campus visits per month. This request must be turned in 7 days before the visit.
Phase 3 (211-280 days) Residents are eligible for one 4-8-hour off-campus visit and one overnight visit per month (upon approval). The overnight visit will be from Saturday after work until Sunday, back by 8:00 pm. This request must be turned in 7 days before the visit.
Holidays and special events/occasions are considered on an individual basis.
All visits are considered a privilege and not a guarantee. The House Administrator will treat each request on an individual basis.
Phone Call Policy
No phone calls for the first 45 days of entry.
Phase One (1-90 days)
No cell phones for the first 210 days in the program.
Residents will be eligible for a cell phone once they reach 211 days. Eligibility will be determined by the House Manager.
Case Management Form
Name: __________________________ Date of Intake: _____________________
Birth Certificate? Yes or No Goal to get it by: _____________________
Social Security Card? Yes or No Goal to get it by: _____________________
Drivers License? Yes or No Goal to get it by: ______________________
Food Stamps? Yes or No Goal to get it by: _____________________
Diploma or GED? Yes or No Goal to get it by: _______________________
Any Degrees? _________________________________________________
Any Trades / Skills? _____________________________________________
Felon: Yes or No
Probation: Yes or No
Any other restrictions: Yes or No
Any Restrictions: ______________________________________________
DCF Case? ___________________________________________________
Children and who are they with? __________________________________
AUTHORIZATION TO RELEASE PERSONAL INFORMATION
I, ___________________________________________ give permission for Sanctuary Mission Inc. to share and exchange information with other agencies, such as: Hospitals (public or private ) , Doctors, Schools, Individuals,or any other party either providing or evaluating the possibility of providing additional assistance for me.
I also give permission for other Agencies, Hospitals ( public or private ) , Doctors, Schools, Individuals, or any other party either providing or evaluating the possibility of providing additional assistance for me to share Information with Sanctuary Mission Inc. for the purpose of providing assistance to me.
This authorization includes the release of medical and psychiatric information pertaining to the above-named party. The above-named party also agrees to the use of images ( Both photographic and video) for Sanctuary Mission. Inc,
I understand that my consent is valid as long as I am living at Sanctuary Mission Inc. and during any related follow-up. ______________ (Initial)
I confirm that ______________________________ has explained the purpose of this form to me and I understand its content.
Signature: ______________________________________ Date:_________________
Staff Signature _____________________________________ Date: _________________
Notice of Non-Trespass
I____________________________________, of lawful age, is not authorized to be on said or adjacent properties once expelled of self-exited due to inappropriate behavior resulting in mandatory exit from Sanctuary Mission, Inc. program, unless prior permission is granted in writing.
Property described as follows:
Located at 7463 W. Grove Cleveland Blvd. and adjacent Unit 4 of Homosassa Plat Book 1 pg 46; lots 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22 blk 172, Homosassa, Florida, 34448
More particularly described as follows:
Sanctuary Mission, Inc. and The Grace House
If you are found on these properties, you will be found in violation of Florida Statute 810.09. And you may be prosecuted to the fullest extent of the law.
Signed Advised Resident/Guest
Emergency Contact Sheet
Name: ___________________________________ DOB: _________________
Past Medical History: ___________________________________________________________________
Current Medications: ___________________________________________________________________
Social Security Number: ___________________________
Name: _________________________________ Relationship: ___________________________
Name: _________________________________ Relationship: ___________________________
Sanctuary Mission Resident Rules
_______ No weapons, firearms, explosive devices, illegal drugs, unauthorized prescription drugs, over the counter drugs, alcohol, abusive language, profanity, illegal activities, pornography, gambling (Lottery, etc.) allowed on this campus at any time
_______You are required to keep staff informed of your whereabouts. All visit passes, and store runs must be approved by staff before leaving the property.
_______ Residents must be at their work therapy assigned locations from 8:30 am to 4 pm. Deviation without approval will be considered a violation of the programming assignment.
_______ The resident will pay any damage due to misuse done to the equipment used on this property by a resident.
_______ Residents' personal living space and all common areas must be ready at all times. Beds must be made daily.
_______ House Administrators have the right to enter and search any area at any time.
All chores, facility maintenance, and daily assignment must be completed before leaving premises for work assignments, off-site employment, and/or off-site case management.
_______ No open or unsealed food or drinks in any room except assigned eating areas. Men's shelter is the day room and dining area. Grace House is the kitchen and dining room.
_______ Any food consumption after 8 pm is snack foods only (*, i.e., popcorn, chips pre-sliced fruit/vegetables.), No food prep is allowed!
_______ Residents must turn in at intake all monies, cash, checkbooks, debit cards, credit cards, and EBT cards, to be held by staff in a safe lock-up area.
_______ All financial needs must be pre-approved by staff after receiving the resident's request form. All purchases made with requested money must be accompanied by a receipt and turned in to staff with, if any, change from a purchase.
_______ No tobacco use is allowed by any resident while in the Sanctuary Mission Recovery Program, Sanctuary campus, or any associated program locations.
_______ Residents are not permitted in anyone else's personal living area, for any reason, without invitation by that person.
_______ All residents must be in assigned sleeping areas from 10 pm until 5:30 am. Lights out and radios off by 10:30 pm, seven days a week. Residents must stay in the facility during these times. Residents must be indoors by 9 pm.
_______ Residents must always stay within their program residency unless work therapy, program events, or staff-approved activity requires the resident to be away from their shelter area. Grace House shelter is off-limits to men, and Men's Shelter is off-limits to women. Common areas must have staff approval before entering.
_______ While residing at the mission, residents may only listen to Christian music.
_______ TV viewing is a privilege. The classroom is off-limits for personal viewing.
_______ Computer use is a privilege. All social media, porn, listening to unapproved music, gaming, YouTube, and the like are prohibited. Computer use is for job searching, case management, resume building, and program needs only.
_______ Residents are required to wear appropriate clothing to off-site program activities. Men are required to wear collared shirts to all church activities.
_______ Vehicle use/storage will be considered on an individual basis.
_______ Insubordination of any type directed toward staff, volunteers, or leadership persons will not be tolerated at any time.
_______ All residents must participate in programming by note-taking, discussions, and/or required homework/curriculum.
_______ Bathroom usage is limited to 15 minutes at a time, one shower per day. Must shower in the evening—one person at a time. No wipes or contraband is to be put down any drain.
_______ Dating is not permitted. Romantic relationships (other than marriage) are not allowed or recognized while participating in this program. Flirting, suggestive speech or action, physical contact, passing of notes, or contact with another person with the purpose of romantic pursuit may result in termination from the program.
_______ All visitations must have pre-approval by staff based on the level of the resident's program status.
_______ No soliciting or accepting personal donations, money, or any other items.
_______ All gifts, donations, personal items, etc. given to any resident must be immediately turned in to staff. You may or may not be allowed to retain the items.
_______ Gang or prison mentality/behavior, bartering, intimidation, or behavior of the like is absolutely prohibited within this program. Violation may be grounds for immediate dismissal.
_______ A proper dress code is always required. Residents are required to wear clothing that will cover their bodies appropriately and respectfully while in this program. Residents must be fully dressed before leaving their personal living space. Clothing must not have any inappropriate symbols, pictures, profanity, death/demonic or sexually suggestive designations, or derogatory verbiage.
_______ Theft, physical abuse, violence, or property damage May result in the termination of your program. Any verbal attacks toward any persons will result in immediate removal from the program.
_______ Residents must stay together as a group when attending off-site activities—staff approval is required to deviate from activity.
_______ No association with former residents unless approved by staff.
_______ There will be no non-staff organized bible studies, prayer, or spiritual events led by residents unless pre-approved by staff.
_________ All mail will be monitored by staff.
_________ Transportation is the responsibility of the resident. Staff may help if possible, ultimately up to the resident to find transportation.
__________ If a resident is terminated from the program they will have 72 hours to pick up personal belongings.