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 45 probationary period for 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 45 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?  __________________________________________

Drug Usage(DOC):___________________________________________________________                                        

Last time you used?:_________________________________________________________

Alcohol Usage:______________________________________________________________

Last time you drank?:________________________________________________________

Detox Needed: Y / N                                        

Active Warrants Y / N

Ever been charged with  Domestic Violence: Y / N

Legal Issues:_____________________________________________________________________

Court Dates:______________________________________________________________________

Probation: Y / N      Misd. / Felony         PO:_____________________________________________

Previous charges/Arrests:____________________________________________________________

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?________________________________________________________________

Additional Notes:_____________________________________________________________________________________________                                   

  

 

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. 

Our Program 

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 & 45day 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. 

 

1-45-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 45 days, you will be eligible for on-campus visits with a written request and work-for-hire income. (See Visitation Policy) 

Education/Training: 

Various topics of recovery and life skills training. 

Work Therapy: 

Assigned work program and job readiness training. 

 Case Management (checklist): 

Working with residents to resolve life hindering issues, court fees, DL, SS, GED, etc. 

 

Financial Accountability: 

Please read our Understanding of Financial Accountability (UFA) memorandum. 

 

 

  

Phase 2: 91-210 Days 

Case Management 

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 

Job Search/Employment: 

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.

 

Mentorship/Sponsorship: 

The resident will begin to search for a sponsor/mentor for continued spiritual development and personal accountability.   

 

Case management 

Continued as needed. Refer to the checklist. 

Visitation Policy 

 

  • No visits during your first 45 days. 

  • All visits are on Sundays after church.  The resident will be back on campus no later than 9 pm.

  • Phase One (45-90 days) Residents are eligible for two on-campus visits per month for up to 4 hours. This request must be turned in 7 days before the visit. 

  • Phase Two (91-210 days) Residents are eligible for two 4-8 hours off-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:  _____________________

 

Documentation:

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:  _____________________


 

Education:

Diploma or GED?  Yes or No                 Goal to get it by:  _______________________

Any Degrees?  _________________________________________________

Any Trades / Skills?  _____________________________________________

 

Legal:

Felon:  Yes or No

Probation:  Yes or No 

Any other restrictions:  Yes or No  

 

Health:

General:  _____________________________________________________

Medications: __________________________________________________

Any Restrictions:  ______________________________________________

 

Family:

DCF Case? ___________________________________________________

Married?  _____________________________________________________

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.


 

________________________________

Dated

 

________________________________

Signed Advised Resident/Guest

 

________________________________

Signed Staff

Emergency Contact Sheet

 

Name: ___________________________________ DOB: _________________

Past Medical History: ___________________________________________________________________

_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Current Medications: ___________________________________________________________________

__________________________________________________________________________________________________________________________________________________________________________

Allergies: _____________________________________________________________________________

_____________________________________________________________________________________

Social Security Number: ___________________________

Emergency Contact

Name: _________________________________ Relationship: ___________________________

Phone: _________________________________

Address: ______________________________________________________________________

______________________________________________________________________________

Emergency Contact

Name: _________________________________ Relationship: ___________________________

Phone: _________________________________

Address: ______________________________________________________________________

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.