Skip to main content

Hit enter to search or ESC to close

Who We Are
How We Help
How You Can Help
Events
Donate
Get Help
Thrift

Renewal Application

Step 1 of 9

11%

Date
MM slash DD slash YYYY
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 Renewal Program.
Name*
First Last
Date of Birth
MM slash DD slash YYYY
Address*
Street Address City State ZIP Code
Phone*
Email
Why should you be selected for the Renewal 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
MM slash DD slash YYYY
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
- separated
- divorced?
Do you have a boyfriend or common law husband?
- 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
Can you commit to remain in the program at least 7 months or until staff recommends completion?
- Yes
- No
(A) Do you want to join Renewal 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 pending or upcoming court dates?
- 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 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 Renewal 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 willing to quit smoking? (This is a non smoking program)
- Yes
- No
Have you ever overdosed?
- Yes
- No
If yes, when?
Month
Day
Year
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 or have you ever been 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 $125 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.
I understand that employment is not allowed until after completion of the program.
- Yes
- No
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 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 Renewal and describe your commitment to changing your life.

Waivers
Check each of the following
I understand that the Renewal program is not a detoxification facility.*
- I agree
I understand that the Renewal Center is not a mental health facility.*
- I agree
I understand that the Renewal program is not a medical program.*
- I agree
I understand that the Renewal program does not pay for any medications.*
- I agree
I understand that as part of the Renewal 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 Renewal 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 Renewal 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 Renewal program.*
- I agree
I understand that the Renewal 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

490 S. Pleasantburg Drive
Greenville, SC 29607

Tax ID 57-0425826

Quick Links

Contact Us
Donor Portal
Media Resources
News Coverage
Employment
Internship Program
Shop Merchandise

Keep Up With Us

Sign Up For Our Newsletter

Affiliations

© 2024 Miracle Hill Ministries. Miracle Hill Ministries is a 501 (c)(3) nonprofit organization. | An Engenius website.

Who We Are
How We Help
How You Can Help
Events
Donate
Get Help
Thrift

© Copyright Miracle Hill Ministries

Finely Tuned by Engenius

Translate »