APPLICATION FOR ADMISSION

STABLE AND FREE EMOTIONALLY RESIDENTIAL PROGRAM

(Please Print and mail or drop it by if in the area...)

Safe Harbor

700 Commercial

Coos Bay, OR 97420

1-541-266-0762

PERSONAL HISTORY

Identification Data

Name:_________________________________________________ Date:_______________ Phone:__________________

Address:__________________________________ City:_________________ State:_________ Zip:____________

Occupation:__________________________________ Business Phone: ___________________________

Gender:_________ Birthdate:__________________________ Age:____________

Marital Status: Married_____ Single_____ Separated______ Divorced_______ Widowed_______

Education: Last grade attended: _________________

Referred here by:___________________________________________________

Marriage And Family Information

Name of spouse:____________________________________ Age:________

Address:_____________________________________ City:___________ State:_________ Zip:_________

Spouse’s education in years:_______ Is spouse willing to come in for counseling?:____________

Have you ever been separated? Yes_____ No______ When? (From)_______________ To(_______________)

Has either party ever filed for divorce? Yes____ No_____ When?_______ Who?________

Date of Marriage:____________ Ages when Married: Husband: _______ Wife:_________

How long did you know your spouse before marriage? __________ year(s)

Give brief information about any previous marriages: _____________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

Names and ages of children: Are they living with you now? Yes_______ No:________

___________________________________________ _____________________________________________

____________________________________________ _____________________________________________

If children are now living with you, explain your plans for their alternative living arrangements during your year with SAFE: (Children are unfortunately not allowed in the live in program.):

Are you required to pay any alimony or child support? If yes, explain.

Do you have any legal obligations or court dates? If yes, explain.

Do you have a PO? If yes, please list:

Name:_________________

Phone:___________________

Are you currently employed? If so, where and what days/hours?

If necessary, will your employer adjust your hours to meet Program guidelines?

Please list three people that you feel are spiritually supportive of you and your decision to enter the Safe Harbor Residential Program.

Name:________________-- Phone:_________________________

Name:________________-- Phone:_________________________

Name:________________-- Phone:_________________________

Religious Background

Religious or Denominational Preference: __________________________________

What church, if any, do you presently attend? __________________________________________________

Church Address?______________________________ City_________________ State___________ Zip ________

Pastor’s Name _______________________________________ Phone _________________________________

May we contact your pastor for information and help? Yes________ No________

Church attendance per month (Average) ______ times per month (including Sunday AM, PM, and midweek)

Religious preference of spouse?_______________________________

Do you consider yourself a spiritual/religious person? Yes______ No______

Do you believe in God? Yes____ No_____ Uncertain_______ Do you pray? Yes_____ No______

Do you believe that you will spend eternity in heaven? Yes______ No_______

Why did you answer the previous question the way you did? ____________________________________________

__________________________________________________________________________________________

___________________________________________________________________________________________

Have you received Jesus as your Savior? Yes____ No_____ Huh?_____

I read the Bible Often____ Sometimes_____ Never______

Explain any recent changes in your spiritual life: ____________________________________________________

___________________________________________________________________________________________

____________________________________________________________________________________________

___________________________________________________________________________________________

Personality data

Have you ever had counseling, psychotherapy, or Biblical Counseling before? Yes____ No____ When? ____________

Circle any words you feel best describe you as a person:

Other words not listed above? __________________________________________________________________

____________________________________________________________________________________________

Have you ever felt that people were watching you? Yes_____ No_____ When? ________________

Do people’s faces ever seem distorted? Yes_____ No_______ When?__________

Are you sometimes unable to judge distances? Yes_____ No_____ When?_______

Have you ever had hallucinations? Yes____ No____ When?___________

How many hours of sleep do you usually get in a night? ________

Describe any recent changes in your sleep habits; _________________________________________________________

_________________________________________________________________________________________________

Health data

My health is: Very good_____ Good______ Average______ Poor________

Weight? ______ Height? ________ Any recent weight change? Yes_____ No_____

Please list ALL present or past illnesses, injuries or disabilities: ____________________________________________

______________________________________________________________________________________________

_______________________________________________________________________________________________

Do the above conditions limit you in any way? Yes____ No____ Explain yes: ________________________________

_______________________________________________________________________________________________

Date of last physical examination:_______________

Doctor’s Name:________________________________ Phone ___________________________________

Do you drink alcoholic beverages? Yes___ No______ When?______ How much per week? ______________________

Are you presently taking ANY over the counter or prescription medications? Yes_____ No______

If yes, Please list meds and their purposes:______________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

Are you now using, or have you ever used, street or illegal drugs, or any medication for other than medical purposes?

Yes_____ No____ Explain yes: (Drugs of choices, when, and how much…) ________________________________

______________________________________________________________________________________________

Attach a separate paper if necessary!

Have you ever had a severe emotional upset? Yes___ No____ When?______

Please give a short description;____________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

Have you ever been arrested? Yes____ No____ When? ___ Charge?_____________________ Outcome? _____________

Basic Problem Identification

1)What is the problem that brings you here?

2)What have you done about it?

3)What do you want from Stable And Free Emotionally?

4)What led you to coming here at this time?

5)If you woke up tomorrow morning and a miracle had happened, and your problems were solved, what would life be like for you?

6)Is there any other information we should know?

Non Christian Spiritual Experience Inventory

Please circle any of the following experiences or belief systems you have been or are involved in:

Other: ___________________________________

Below This line for Office Use Only

Date received:

Case #:

Date of pre-admission interview:

Accepted?

If no, reason?

Possible future admission?

Waiting list?

Possible entrance date?

Safe Harbor Residential Program Guidelines

Providing Safe Haven in the Midst of Life’s Storms

Length of Commitment: Please be aware that Safe Harbor does not provide short term answers to long term problems. We do not provide temporary housing, financial assistance, or any other form of short-term assistance. You are making a commitment to a one-year program of Renewing the Mind. (Romans 12:1-2) At any time you may choose to leave, but your re-entrance to the Safe Harbor Residential Program may occur only after a thirty day period, and may be dependant on other factors. If your participation in Safe Harbor is court-mandated, please be aware that your departure from the Program may result in court action against you, or re-entry into the Jail/Prison system. SAFE HARBOR MAKES NO ATTEMPT TO DETAIN PROGRAM PARTICPANTS.

Zero Tolerance: The Safe Harbor Residential Program maintains a zero tolerance level for drug and alcohol use, misuse, or abuse. Safe Harbor Residential Program participants shall not have in their possession, in their rooms, or in or about the premises any alcoholic beverage, including but not limited to, beer, "near" beer, wine, wine coolers, distilled liquor, or mixed drinks containing any form of alcohol. Safe Harbor Residential Program participants shall not have in their possession, in their rooms, or in or about the premises any mood altering drug, prescription or non-prescription, unless accompanied by a legitimate prescription from a medical doctor for a legitimate medical and/or psychological condition. (These medications shall be kept in a locked cabinet in the Program Director’s office and shall only be released to participant according to the doctor’s schedule of dosage and as needed within that schedule of dosage.)

Safe Harbor Residential Program participants shall not be visibly under the influence of any alcoholic beverage, or any mood altering drug, prescription or non-prescription, unless accompanied by a legitimate prescription from a medical doctor for a legitimate medical and/or psychological condition. Safe Harbor Residential Program participants shall not carry with them the odor of alcoholic beverages. ANY violation of this Zero Tolerance Policy SHALL result in disciplinary action as outlined in this document.

Personal Conduct: Safe Harbor Residential Program participants shall govern their personal conduct according to the Golden Rule given by Jesus: "Do unto others as you would have them do unto you", and according to Jesus’ words; "You shall love your neighbor as you love yourself." To help you apply these words, we offer the following guidelines;

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• Respect others and respect yourself. Respect the privacy of others. Respect the belongings of others. (Don’t touch anything that doesn’t belong to you without permission from the owner!) Remember that the Safe Harbor Residential Program is your home, and the home of others, for the duration of your stay.
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• Treat one another with kindness. God tells us that everything that comes out of our mouths should serve to build others up, not tear them down. Therefore, putdowns, demeaning remarks, insults or offensive remarks of any kind will simply not be tolerated. (Safe Harbor Residential Program staff will be the final judge on what constitutes unacceptable remarks.) The Safe Harbor Residential Program also has a Zero Tolerance for remarks of a sexually offensive nature. Sexual harassment of any kind will not be tolerated. Remarks with sexual overtones, double meanings, or veiled or explicit sexual content, whether consensual or not, will not be tolerated. Remarks of a racially offensive shall also not be tolerated.
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• If you open it, close it.
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• If you turn it on, turn it off.
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• If you unlock it, lock it, (or vice versa as the situation calls for!)
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• If you break it, fix it or admit it and ask someone who can.
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• If you borrow it, return it.
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• If you make a mess, clean it.
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• If you move it, put it back.
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• If you don’t know HOW to use it, don’t use it.

Food: You will receive three well balanced, healthy meals each day (Mon-Fri) prepared by our kitchen staff. On weekends, you will be expected to provide your own meals, using either foodstuff in the common pantry or purchased by yourself. Due to the possibility of "critters" in the rooms, no food items are allowed in the dorm areas, except as allowed by and under the supervision of staff.

Romantic/Sexual Relationships: Your time at the Safe Harbor Residential Program is meant to be a time of focusing on the dynamics of recovery. You will be dealing with emotional and spiritual issues that will demand a great deal of your emotional energy. Therefore, romantic or sexual relationships of any kind between Safe Harbor Residential Program participants are strictly prohibited. Romantic relationships between Safe Harbor Residential Program participants and those outside of the program are strongly discouraged. Sexual relationships of any kind outside of the bonds of marriage are a clear violation of Biblical principle, and are prohibited within the Safe Harbor Residential Program. (Please see attached Relationship Agreement)

Staff/Safe Harbor Residential Program participant interaction: When asked/requested to do a task by a staff member of Safe Harbor Residential Program, whether paid or volunteer, you are expected to do as asked. After completing the task, you are expected to check back with the staff member to report that the task is finished, and to request any further instruction. Unless following an instruction would place you or others in physical danger or in violation of local laws or Biblically based moral principles, you are expected to follow such instruction, whether you agree with it or not. If you feel that a staff member has violated your "rights", you may make an appointment with the Program Director to discuss the situation. The Program Director’s decision regarding the situation/disagreement is final.

Remember that everyone in the Program has a problem with authority when they first come here. If they didn’t, they wouldn’t need the Program! It’s best to accept this and relax in the need for authority and discipline. Everyone, at all times, is accountable to someone. Many times, we are accountable to more than one person. If you find that you are having problems with authority figures in the Program, make yourself talk about it. Talk to some of the people who have gone through the program. We have all been there!

Safe Harbor Residential Program participant schedule: Unless specifically excused in writing by the Program Director, you are expected to follow the attached Daily Schedule. Any deviation from the schedule without written permission shall result in disciplinary action as outlined in this document.

Safe Harbor Residential Program work guidelines: You are encouraged to work at outside employment, if this is available to you, and you are able to do so. However, outside employment is subject to the following restrictions;

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• The evening meal (5 PM) is mandatory. All Safe Harbor Residential Program participants must be physically present for the evening meal, as this time together is essential in building a sense of family and instilling trust in one another.
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• The evening activities from 5 PM to 7 PM (this may vary on some nights) are mandatory. NO ONE will be excused from evening activities, including but not limited to, SAFE, Self-Confrontation, and Church services, without written permission from the Program Director. Please bear in mind that written permission will not be given unless an emergency situation exists.
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• If you return from work visibly intoxicated in any way, or attempt to bring "contraband" [as defined by staff] items into the Safe Harbor Residential Program building, (Safe Harbor Residential Program staff reserves the right to conduct safe, non-intrusive searched) your privilege of outside work will be revoked. If this results in an inability to pay program costs, you may be terminated from the Safe Harbor Residential Program.
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• The Program Director will have final say on outside work issues.
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• Safe Harbor Residential Program participants not working outside the Safe Harbor building will be assigned work in or about the building. This work shall not be for the purpose of "payment" towards program costs. This work shall be part of the total program of renewing the mind, as you will learn proper work habits, self-discipline, teamwork, and other issues, which will be invaluable to you, as you re-enter the work force. Please remember, that this work is not "slave labor", but is a necessary part of the total program of the Safe Harbor Residential Program, and will also serve to raise your personal sense of positive worth.
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• If you are looking for work, your contacts must be documented daily.

Church Attendance: As a necessary part of your spiritual development, you will be required to attend all scheduled and special Church Services in the Safe Harbor Residential Program. This includes, but is not limited to, Sunday AM, Sunday PM, S.A.F.E. meetings, mid-week meetings, and special/revival meetings. Unless specifically excused in writing by the Program Director, absences or excessive tardiness shall result in disciplinary action as outlined in this document. Attendance at other area churches/ministries will be approved on a case by case basis after the Program Director meets with the Pastor or Minister of the church or ministry.

Loitering/Trespassing: Safe Harbor Residential Program participants shall not loiter in or about the building at any time of the day or night. There will be NO "hanging around" outside the building in any area visible to the general public. If you are not involved in a scheduled or directed event or work, you will be expected to be in your room, in a common area, or anywhere that has been approved by the Program Director or those the Program Director may designate as Floor Directors. Safe Harbor Residential Program staff shall know your location at all times.

During evenings and weekends when no scheduled activities are taking place, you will be free to leave the Safe Harbor Residential Program building upon completing a sign out process, listing your time of departure, destination, phone number and contact person, and time of arrival back to the Safe Harbor Residential Program building. If you are NOT at the designated location, or if you return late, disciplinary action as outlined in this document shall take place.

Safe Harbor Residential Program participants shall not be in any of the following areas, without staff approval and/or reason of personal invitation or scheduled activity;

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• The entire second floor of the building. This is a residential area for paid and volunteer staff of the Safe Harbor Residential Program.
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• The church and office area on the third floor.
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• The roof. (Your presence on the roof may result in your termination from the program.)
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• The eastern half of the house.
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• The "condo" on the fourth floor.
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• The Kitchen area and offices on the first floor.
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• Any other areas specifically prohibited by staff.

Isolating: As it is clear that many of our emotional and spiritual problems stem from our tendency to "dwell" upon the events of the past, and because we tend to do this "dwelling" while spending time alone, Safe Harbor Residential Program participants shall not isolate themselves from other participants. "Isolating" is defined as spending excessive time by yourself, and/or avoiding the company of others. Safe Harbor Residential Program staff will have the final determination on what constitutes isolation.

Smoking/tobacco use: As tobacco has been shown to be an addictive drug with harmful effects, use of tobacco in any form is strongly discouraged. However, we recognize that many Safe Harbor Residential Program participants have deeper issues to be working on, so while we encourage utilizing the S.A.F.E. principles to overcome this addiction, we also provide ONE designated smoking area; in the alley on the NORTH side of the building. NO OTHER AREA is a designated smoking area, and violation of this policy shall result in disciplinary measures as outlined in the document, and MAY result in a 24-hour notice of termination.

Sick Call: If you are sick, please inform the Program Director or Floor Manager of this by 8 AM. Please remember that that if you are too sick to take part in daily scheduled activities, you are also too sick to wander the building, socialize with others, or otherwise spend time outside of your room. If on sick call, you are expected to stay in your room and rest. Staff will bring simple meals to you in your room. Abuse of sick call privileges may result in disciplinary action as outlined in this document. Staff may require your illness to be confirmed by medical personnel. Staff must approve all prescriptions before they can be filled.

Disciplinary Procedure: In the case of violation of these guidelines to such a degree that disciplinary action is needed, such action shall consist of the following;

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• First offense: Verbal warning by the Program Director, with notation of this in your file.
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• Second offense: Written warning by the Program Director, including a statement that a third offense shall result in program termination
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• Third offense: Termination from the program with 24 hours notice.

Please bear in mind that disciplinary actions are not meant to punish anyone, but to help you to make right choices. Every choice we make in life has a consequence, either positive or negative. In the Safe Harbor Residential Program, we will help you to be accountable for your own actions and decisions.

Program Costs: All Safe Harbor Residential Program participants shall be expected to pay program costs of $750 per month made payable to Healing Word Ministries. (Bear in mind that most recovery programs charge between $3000- $4000 per month!) Our goal is to make the process of recovery affordable for everyone. Although we would like to provide this service free of charge, we cannot, as your program costs go towards covering these costs; (Only a partial listing!)

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• Food
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• Electricity
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• Water
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• Insurance and bonding
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• Staff salaries
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• Printing costs
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• Supplies
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• Phone
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• Publicity and advertisements

Mail/Phone usage: All Safe Harbor Residential Program participants shall receive mail as follows:

[Name]

C/O Safe Harbor

700 Commercial Ave.

Coos Bay, OR 97420

Your incoming mail will be made available to you during a daily mail call. All packages and/or bulky envelopes will be opened in front of Safe Harbor Residential Program staff. Safe Harbor Residential Program staff reserves the right to have any and all mail opened in their presence.

The Safe Harbor phone number is 1-541-266-0762 All incoming calls shall be answered, "Good (Morning/Afternoon/Evening), Safe Harbor!" All outgoing calls shall be made only with the knowledge of staff. There is a partial block on long distance calls. To make a long distance call, staff assistance is required. All long distance calls shall be logged, and the Safe Harbor Residential Program shall be reimbursed for such calls. In order to help develop a sense of family and a sense of personal and family responsibility, any unexplained and un-reimbursed long distance phone calls MAY result in a loss of phone privileges for all Safe Harbor Residential Program participants for a pre-determined period of time. In other words, if you did it, admit it!

Personal phone calls shall be limited to 15 minutes, incoming or outgoing, and residents shall not make nor receive more than 2 phone calls in a one-hour period. Phone calls shall be made or taken only during scheduled breaks or free time, except for emergency situations.

Phone usage, incoming or outgoing, shall cease each night at 9:00 PM.

Personal Money/Checks;

Residents shall not receive any monies or cash any checks without the knowledge of and permission of Program Staff. Residents shall not lend nor borrow money to or from other residents or Program Staff.

Personal & Common Areas/Personal Hygiene/Personal Apparel: You will be expected to maintain a clean living area at all times. Room inspections MAY occur daily. Staff will explain to you the expected state of cleanliness. You will be expected to follow staff expectations!

You will be expected to maintain a high state of personal hygiene. You will shower/bathe daily; Use deodorant as needed: Males will shave daily and/or keep beards, sideburns, mustaches, etc. in neatly trimmed condition. Both men and women will ensure that hair is combed/brushed neatly and styled appropriately. No "extreme" hairstyles will be allowed. (As defined by staff)

Clothing worn shall be in serviceable condition with no visible tears/holes. An exception to this MAY occur when work conditions demand old clothing. Clothing shall be modest at all times. Safe Harbor Residential Program participants shall not be in any common area (where both males and females are…) in underwear, nightwear, or provocative clothing of any kind. Safe Harbor Residential Program participants shall not wear T-shirts, shirts, or sweatshirts with any message, in words or pictures, which depict or glorify alcohol or drug use, "heavy metal" bands, or any offensive words of any nature, whether "curse" words, racial slurs, sexual comments, or ANY OTHER message/picture deemed offensive by staff.

Personal Responsibility: As the Safe Harbor Residential Program is a Residential Recovery Center rather than a Residential Treatment Facility, staff will NOT be responsible for ensuring your timeliness in being where you are supposed to be. It is YOUR RESPONSIBILITY to be awake at the proper time, present at all meals as required, present at all scheduled activities, etc. Excessive tardiness or absence from scheduled activities without permission will result in disciplinary action as outlined in this document.

Misc. Guidelines:

What’s Allowed:

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• Snacks and meals and you desire- Dinner Monday-Friday is Mandatory!
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• Leaving the building in the company of an approved person while on First Thirty-Day’s Restriction.
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• Reading your Bible and studying SAFE principles any time you need to or want to.
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• Listening to Christian music out loud.
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• Listening to music of your choice with headphones.
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• Use of any available exercise equipment.
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• Spending a few minutes in your room cleaning every day.
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• Smoking in approved smoking area.
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• Visitors with staff approval, between the hours of 9 AM and 9 PM. (No visitors in your room!)

What’s Not Allowed:

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• Putting anything before God.
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• Eating anything with anyone’s name on it.
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• Eating anything designated for Program meals.
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• Leaving dirty dishes.
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• Lending or borrowing money.
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• Unauthorized relationships.
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• Giving out building keys or combination.
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• Washing clothes on Sunday Morning.

Additions/Amendments to guidelines: These guidelines may be amended or added to at any time by the Program Director. You will receive written notification of such additions or amendments.

Until such amendments/additions are put in writing, they shall be considered as if in writing. In other words, if a Safe Harbor Residential Program staff member gives an instruction or request not covered in these guidelines, until and or if they are overruled by the Program Director, such instructions or requests shall be considered to be part of the Safe Harbor Residential Program guidelines.

DAILY SCHEDULE (M-F) FOR

SAFE PROGRAM PARTICIPANTS

All Program Participants shall be present at the evening meal.

Evening free time includes the time for personal chores, laundry, etc.

Agreement Form

I am committing to one year in the Safe Harbor Residential Program. I agree to attend all mandatory functions, complete all assignments and do all assigned chores. I will follow all Program Staff instructions to the letter, including submitting to UA’s when requested.

I agree to not cash any checks or spend any money without first reporting such income to Program Staff. I voluntarily put myself under the authority of Program Staff and understand that any violation of Program guidelines will result in disciplinary action, including the possibility of expulsion from the Program. I waive any right to thirty days notice of such expulsion.

I agree to pay $750.00 per month for twelve months to cover the cost of the Program. This fee covers my room and board, counseling, support group meetings, and all other administrative costs. I agree to pay a one-time charge of $25 for Program Materials. I agree to pay for all UA’s required by staff. I understand that all Program fees may be paid up front instead of monthly.

I agree that in the event of my voluntary or involuntary termination from the Program, there will be no refund of any fees paid.

I agree that any personal belongings left in the building after 4 days shall be considered as having been donated to the Program.

I have fully read all guidelines and attached forms, and agree and submit to all terms and guidelines as stated.

I understand that any "counseling" given by Program Staff shall be Biblically based, and it is my option as to implement the "counseling". I agree that Program Staff shall be held blameless as to the results of such "counseling", and/or my understanding or misunderstanding of such "counsel."

Signed ___________________________________ Date______________________

Safe Harbor Relationship Agreement Form

During this year, we strongly encourage you to focus on your relationship with God and Jesus Christ. Any other relationships with the opposite sex you choose to develop will be structured according to the following guidelines.

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• NO unauthorized relationships
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• NO relationships during first cycle
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• During your second cycle, all relationship outings (dates) must be in the company of another resident who is not on 30 day restriction.
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• Your relationship partner must be attending weekly SAFE meetings as an outpatient.
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• Any deviation from this agreement will result in loss of this privilege.
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• Staff will define what is and what is not a healthy relationship.
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• These guidelines will be added to or taken away from at the discretion of Staff.
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• No public display of affection, other than holding hands.

In our experience, we have seen many lives destroyed and the resident’s commitment to God broken because of unhealthy relationships. This is the reason for these guidelines.

I understand and agree to the above agreement.

Signed_______________________________ Date___________________

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