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Overcomers Application
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The following information is considered confidential and will be dealt with as such. Your complete and honest answers will assist us in determining your eligibility and prevent delays in entering the program. Intentionally falsifying any answers could result in being disqualified from the Overcomers Program.
Name
*
First
Last
Address
*
Street Address
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Phone
*
Email
Why should you be selected for the Overcomer's Program?
Problem Areas
Are there any legal, medical, financial or relationship issues that could prevent you from completing the program?
Yes
No
Are you the one seeking help and are you willing to accept counsel?
Yes
No
Please list any substances or activities to which you are currently or have been addicted to in the past. Please list these in the order of frequency of use.
Substance 1
Substance 2
Substance 3
Substance 4
Alcohol
Have you ever been to Detox?
Yes
No
if yes, where?
List prior treatment facilities you have entered
Date of your last drug or alcohol use
What did you use?
How long have you been using?
Finish this statement:
With God's help, and as a result of this program, I would like to change my life in the following five areas:
Area 1
Area 2
Area 3
Area 4
Area 5
Check the five most prevalent thoughts and attitudes that are ongoing or dominant in your life:
Excessive suspiciousness
Selfishness
Anger (displayed)
Hostility
Immoral thoughts
Impulsiveness
Regrets
Self-pity
Resentment
Bitterness
Worry
Daydreaming
Constant Pessimism
Envy
Check five to seven words that best describe you:
self-conscious
sensitive
active
nervous
persistent
self-confident
hardworking
impatient
moody
excitable
serious
calm
easy-going
good-natured
outgoing
likeable
leader
quiet
submissive
shy
lonely
ambitious
Relationships
Are you currently
married
single
separated
divorced
Do you have a girlfriend or common law wife?
Yes
No
I understand this person will not be allowed to communicate with me in any manner during the course of this program.
I Accept
Can you accept instructions?
Yes
No
(A) Do you count the days or (B) can you commit to remain in the program until staff recommends completion?
A
B
(A) Do you want to join Overcomers or (B) do you feel forced to join?
A
B
When you are confronted on issues, how do you normally react?
Legal History
Have you ever been arrested?
Yes
No
If yes, please give the date of the arrest (month/year), reason for the arrest and the outcome:
Attorney Name
First
Last
Attorney Phone
Are you a listed sex offender?
Yes
No
Do you have any outstanding warrants?
Yes
No
Are you on probation/parole?
Yes
No
If yes, please explain:
Probation/Parole Officer Name
First
Last
Probation/Parole Officer Phone
Are you involved with social services?
Yes
No
Are you or should you be paying child support?
Yes
No
Case worker Name
First
Last
Case worker Phone
Health History
FALSIFYING MEDICAL INFORMATION IS GROUNDS FOR DISMISSAL FROM THE OVERCOMERS PROGRAM
Height
Weight
Hair Color
Eye Color
Would you say your health is
Very Good
Good
Average
Declining
Poor
please explain:
Vision
Good
Fair
Poor
Mobility
Good
Fair
Poor
Overall Health
Good
Fair
Poor
Hearing
Good
Fair
Poor
Do you have problems in any of the following areas?
Dental
Back
Neck
Orthopedic (bone)
Heart
High blood pressure
Diabetes
Asthma
Allergies
Other
Other:
If yes, describe your medical condition and how it impairs your life:
Are you currently taking any prescribed medications for these conditions?
Yes
No
If yes, what medications?
Have you been prescribed medications for these conditions which you are not taking?
Yes
No
If yes, what medications?
Do you have any physical limitations that would prevent you from participating fully in the Overcomers Program?
Yes
No
If yes, please explain?
Can you sleep in a top bunk bed?
Yes
No
Your Doctor's Name
First
Last
Your Doctor's Phone Number
Do you smoke?
Yes
No
If yes, how many years?
Packs per day?
Would you be willing to quit smoking?
*
Yes
No
N/A
Have you ever overdosed?
Yes
No
If yes, when?
MM
DD
YYYY
Do you have allergies?
Yes
No
If yes, what?
Were you abused as a child?
Yes
No
If yes, what type?
Physical
Sexual
Verbal
Briefly explain
Do you have a history of mental illness in your family?
Yes
No
Are you currently a mental health client?
Yes
No
If yes, please list your therapist(s) name and location:
List all mental health medications you have been prescribed and are currently taking:
List any mental health medications prescribed that you are not currently taking and why you stopped taking them:
Family History
Give a brief description of your childhood home environment:
Father
Stepfather
Name
First
Last
Age
Occupation
Describe your relationship with him
Mother
Stepmother
Name
First
Last
Age
Occupation
Describe your relationship with her:
How many siblings do you have?
What place are you in the birth order?
Describe your relationship with your siblings as you were growing up:
Give a brief description of what it was like growing up in your family: (praise, criticism, punishment, trauma, accomplishment)
Were you ever placed in foster care?
Yes
No
If yes,explain?
Did your family move a lot?
Yes
No
Are you currently living with your birth family?
Yes
No
If there are children or step children in your home, describe your relationship with them:
Financial Assesment
A program entry fee of $85 is required to enter the program. There are a limited number of scholarships available for those with extreme hardship situations. Additionally, those with an income are expected to contribute toward the cost of the program. The fees are based on a sliding scale and no one will be denied access to the program due to a lack of funds. Financial arrangements will be discussed during the phone interview.
What is your preferred occupation?
When were you last employed?
Do you currently have an income?
Yes
No
What is the source of your income?
Unemployment
Disability
Insurance
Family
Trust Fund
SSI
Social Security
Other:
Other
List all of your financial obligations and amounts: (child support, car payment, restitution, parole/probation fees, etc)
How will these obligations be met while you are in the program?
Is there anyone who would be willing to help with your expenses while you are in the program?
Yes
No
If yes, who and to what extent?
If you leave the program prior to graduation, you will need to return to your community of origin. A friend or family member will need to pick you up or someone will need to provide a bus ticket for you. You may also bring a bus ticket with you when you arrive. Who will be responsible for this?
Name
First
Last
Daytime Phone
Cell Phone
Address
Street Address
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
I will bring a bus ticket with me when I arrive.
Spiritual Assesment
Have you been, or are you now affiliated with any organized religion?
Yes
No
If yes, what is the name & type
Do you currently attend services?
Yes
No
If yes, where?
Leader's Name
First
Last
Are you satisfied with your spiritual health?
Yes
No
Is spiritual growth important to you?
Yes
No
State in your own words why you need to join Overcomers and describe your commitment to changing your life.
Waivers
Check each of the following
I understand that the Overcomers program is not a detoxification facility.
*
I agree
I understand that the Overcomers program is not a medical program.
*
I agree
I understand that the Overcomers program does not pay for any medications.
*
I agree
I understand that as part of the Overcomers program I will be assigned a task assignment and I waive my right to legal action against Miracle Hill Ministries and its representatives if I am hurt during that task.
*
I agree
I understand that Miracle Hill provides limited transportation to me while participating in the Overcomers program and I waive my right to legal action against Miracle Hill and its representatives if injured while being transported by any of the ministries vehicles.
*
I agree
I understand that the Overcomers staff may direct me to transitional housing for a period of time between 6 and 12 months. I also understand that refusal to accept that recommendation may be grounds for separation from the Overcomers program.
*
I agree
I understand that the Overcomers program is not a licensed treatment center and I waive my right to legal action against Miracle Hill, its staff or volunteers based on any counsel I receive.
*
I agree
