Moriah House Intake Form - Memphis Union Mission

Moriah House Initial Intake Form

Initial intake form for Moriah House, Memphis Union Mission’s recovery program for women.

"*" indicates required fields

Date*

Email*

Name*

First Last

Do you have any alias names?

Date of Birth*

Phone*

Age*

Are you a registered sex offender?*

Moriah House is a long-term Christian Recovery Program. Our program lasts one year and includes recovery bible studies, Celebrate Recovery classes, practical living classes, church attendance, one-on-one counseling, as well as cooking and cleaning assignments. We have a daily schedule that everyone follows which provides structure for the entire day. Do you feel that there is anything that would prevent you from participating in these activities?*

• There is no alcohol, illegal/restricted drugs, or smoking allowed here. Is that a problem for you?*

• There is no dating or contact with male friends whatsoever. Will this be a problem for you?*

• Clients cannot have personal cell phones until they begin working or at six months (only when going to work or on passes). However, there is a land line available for you to make business calls during scheduled times. Is that a problem for you?*

• Clients cannot have outside jobs for the first six months. Is that a problem for you?*

• Have you ever been diagnosed with a mental health illness?*

• If yes, what was the diagnosis?

• What medication are you currently taking for the diagnosis?

• Have you had the COVID-19 vaccine?*

If so, when?

Do you have proof of vaccination?

Do you have children?*

Will any children be coming with you? (Maximum three (3) per client, no boys over the age of ten (10) years.)*

Name

First Last

Age

Name

First Last

Age

Name

First Last

Age

Are you wanting recovery for a drug or alcohol addiction?*

If you are seeking recovery for a drug addiction what is your drug of choice?

Are you currently pregnant?*

How many months are you?

Are you a recent victim of domestic violence?*

When was the last incident?

Is your abuser the father of your child/children?

ALL CLIENTS WILL BE PLACED ON A 30 DAY PROBATION PERIOD WHEN THEY ENTER THE PROGRAM. YOU MUST PROVIDE A NEGATIVE TB TEST AND PROOF OF COVID-19 VACCINE BEFORE ENTERING THE PROGRAM.