Merci's Refuge Application Form

Initial Information

First Name*

Last Name*

Name You Go By

Present Address *

Address Line 1

City

State

ZIP Code

Phone Number*

May we leave a voicemail if needed?

Email Address*

Referred by

Family Friend Church Counselor/Caseworker DCFS/DHS Court TV Radio Internet

Have you ever applied to Merci's Refuge in the past?

Yes No

If Yes, give approximate date:

Goals, Motivations & Support

What is going on in your life currently that leads you to desire help and healing through participating in the program at Merci's Refuge?

What are your most important goals in the next 4-12 months?

What are your biggest motivations for working on these goals?

What supportive relationships do you have, if any?

What kind of support, structure, or accountability from others has been helpful for you in the past, or you think would be helpful now?

Are there any significant life/family circumstances that would make it difficult to be away for several months?

Personal & Family Information

Date of Birth*

Age

Address

City

State

ZIP Code

Do you have any children?

Yes No

If Yes, how many?

List names and ages:

If someone else has custody of your child(ren) please list their name and their relationship to your child(ren):

If someone else has custody of your child(ren) please describe your desires for visitation:

If you have children in your care what arrangements are you considering for them while you are at Merci's Refuge?

Are you currently pregnant?

Yes No

If Yes, approximate due date

Has a doctor confirmed your pregnancy?

Yes No

What options are you considering for your pregnancy?

Parenting Adoption Abortion Undecided

(select all that apply)

Education & Employment

What is the last grade and/or training (i.e. CNA, EMT)you have completed?

Some middle school Completed middle school Some high school Completed high school Some college Completed college Some professional training Completed professional training

(select all that apply)

What are your plans for further education and/or training while at Merci's Refuge?

Not seeking schooling/training at this time Complete GED/High School diploma Take college courses Continue professional training

(select all that apply)

Do you have a disability or learning difficulty that may affect your learning?

Yes No

If Yes, please explain

Are you currently employed?

Yes No

If Yes, please describe your job

While in the first program phase of Merci's Refuge (4-5 months), residents are unable to work.

Medical Information

Do you currently have health insurance?

Yes No

If Yes, what is your provider?

Please indicate any serious health problems, surgeries, and medical hospitalizations, past and current:

Describe any physical limitations you may have and any accommodations you may need in a residential setting:

Please share any upcoming medical appointments, and/or needs to establish care

(primary care, dental, vision, psychiatry, OB-GYN, etc)

Please list all medications you are currently taking:

Please list any allergies:

Are you on a special diet?

Yes No

If Yes, please explain:

Do you have, or have you ever had, a problem with food or eating?

Yes No

If Yes, please explain:

Have you ever been diagnosed with an eating disorder or treated by a physician for food-related issues?

Yes No

If Yes, please explain:

Benefits & Financial Information

Residents are required to apply for Link (SNAP- food stamps) and WIC (if applicable) to help with the costs of food for themselves or their babies.

Residents who receive disability benefits may also be required to contribute a small portion toward food costs if they do not qualify for Link.

Please indicate if you receive, or have applied for, any of the following benefits

Link (SNAP) WIC Disability/SSI/SSDI

Merci's Refuge provides food, shelter, basic toiletries, and counseling/support services. We are not responsible for medical expenses or prescriptions. It is the responsibility of the resident and/or her sponsor(s) to cover these expenses. Arrangements must be made in advance of residency. If none of the below sources of support are available to you please inform Merci's Refuge staff during your intake interview.

Please list those (family, church, ministry, individuals) who are willing to help sponsor your personal financial needs while at Merci's Refuge:

Legal Information

Do you have any pending court dates/case?

Yes No

If Yes, please explain and include which State(s) or County(ies) are involved:

Will you be required to appear in person during your time at Merci's Refuge?

Yes No Unsure

Are you currently incarcerated?

Yes No

If yes, please explain what you are incarcerated for and indicate your anticipated release date:

Are you currently on probation or parole?

Yes No

If Yes, please explain the terms of your probation/parole, and which State/County it is in:

How often do you report?

Probation/Parole Officer's Name:

Probation/Parole Officer's Address

Address Line 1

City

State

ZIP Code

Probation/Parole Officer's Phone

Addiction History

If your use was on an ongoing basis, please list below:

(Drug / Age started using / Still Using-Stopped Using / Last Time Used)

Have you ever been in an addiction recovery or detoxification program?

Yes No

If Yes, please list:

(Date of Entry / Name of Program / City/State / Reason for Leaving-Date of Discharge)

Mental Health & Counseling History

Please list any mental health symptoms you have experienced in the last 6 months:

Please list any mental health diagnoses you have been given, or have received treatment for:

Have you ever received inpatient or outpatient counseling, mental health services, or psychiatric care?

Yes No

If Yes, please list:

(Date of Entry / Program/Counselor / City/State / Reason for Leaving-Date of Discharge)

Spiritual/Religious Beliefs

Please describe your experience with religion and/or current your spiritual beliefs:

Please describe any past or current church involvement:

Merci's Refuge is available to women of any religious background. However, its counseling programs are based on the Bible and beliefs of Christianity. Are you open to considering what the Bible has to say about the goals you have for your life or the emotional wounds you are seeking healing from?

Yes Yes, but I have questions/concerns No

Traumatic Experiences

Often negative thoughts, emotions and behaviors that people desire to change are rooted in past traumatic and hurtful experiences. Many of our team members have experienced abuse in one form or another at some point in their life. We know it can be extremely difficult to walk through, acknowledge or discuss. Merci's Refuge is an intensive program designed to bring healing to deep emotional wounds, and it is important for us to know that our residents are ready to acknowledge their pain and are willing to pursue healing and freedom. If comfortable, please list the traumatic experiences you have experienced:

If comfortable, please indicate any traumatic events you have experienced in the past 6 months. Or write "will share at a later time":

If anyone aided in the completion of this application, please indicate below:

Full Name

Relationship to Applicant

Contact Information

Initial Information

Goals, Motivations & Support

Personal & Family Information

Education & Employment

Medical Information

Benefits & Financial Information

Legal Information

Addiction History

Mental Health & Counseling History

Spiritual/Religious Beliefs

Traumatic Experiences

If anyone aided in the completion of this application, please indicate below:

Thank you for answering these questions. Please click the Submit button below.