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*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

S.S.#*

Are you a registered sex offender?*

Moriah House is a long-term Christian Recovery Program. Our program lasts one (1) year and includes recovery Bible studies, Celebrate Recovery classes, relationship classes, practical living classes, exercise, 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 whole day. Are you physically able to participate in these kinds of activities?*

Do you have a mental health diagnosis?*

Are you currently taking any medication? If yes, please list below.

Do you have an open case with Child Protective Services?*

Do you have children that will 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 currently homeless?*

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 weeks are you?

Are you a recent victim of domestic violence?*

Do you currently have an Order of Protection?

Do you agree to not use alcohol, illegal/restricted drugs, or smoke while at Moriah House?*

Do you agree to not date or contact male friends while at Moriah House?*

Do you agree to commit to 6 months of counseling and classes and begin working at 7 months?*

Do you agree to not use a personal cell phone for the first 7 months while at Moriah House?*

Have you been in Moriah House in the past?*

Did you complete the program?