A. FAMILY MATTERS - 2/7

B. PERSONAL HISTORY AND STATUS 3/7

C. LEGAL/FINANCIAL STATUS - 4/7

D. SPIRITUAL HISTORY - 5/7

E. OTHER ISSUES - 6/7

AGREEMENT - 7/7

I understand that this is a faith based program and that Biblical Instruction, studies and prayer are mandatory components of the New Life Program.

CONFIDENTIALITY NOTICE/RELEASE OF INFORMATION The confidentiality of alcohol and drug abuse client records maintained by this program is protected by Federal law and regulations. Generally, the program may not say to a person outside the program that a client attends the program, or disclose any information identifying a client as an alcohol or drug abuser UNLESS: 1. The client consents in writing; 2. The disclosure is allowed by a court order; 3. The disclosure is made to medical personnel in a medical emergency; or 4. The client presents a threat to themselves or another person while in the residency program. Violation of the Federal law and regulations by a program is a crime. Suspected violation may be reported to appropriate authorities in accordance with Federal regulations. Federal law and regulations do not protect any information about a crime committed by a client either at the program or against any person who works for the program or about any threat to commit such a crime. Federal laws and regulations do not protect any information about suspected child abuse or neglect from being reported under State law to appropriate State or local authorities. (42 CFR Part 2 for Federal regulations.) You are further authorized and directed to release any and all psychiatric or psychological records and all drug and/or alcohol treatment or rehabilitation records, billings, reports, and any related material. You are further authorized to release originals or copies of any and all records and to discuss said records with a representative of the Redwood Gospel Mission appropriately identified as such.

acknowledge that I have received a copy of this form and have read, understood, or have had the above summary explained to me as attested by my signature below. I hereby grant my permission for RGM New Life Recovery Program to contact/communicate with all parties in matters directly or indirectly related to my treatment.

Manna Home

A ministry of the Redwood Gospel Mission

2032 Dennis Ln., Santa Rosa, CA. 95403 Phone: 707.576.1471 Fax: 707-576-7808

New Life Recovery Program Application for Admission

This is a huge step forward in your recovery. It takes a tremendous amount of courage to even apply to a program. We hope to be an encouragement to you as you move forward. We are not here to judge you; we are here to help. Please know that your information will be treated with the utmost respect for privacy. Any information obtained is for the sole purpose of determining if this program is a good fit for your needs and will not be released to any outside agency for any reason without your specific written consent to such a disclosure.

There are a few things we would like to tell you about our program up front:

1. We are faith based. You do not need to be a Christian to enter and we do not require that you become a Christian at any point in the program. However, our program is Bible-based and we do lead our classes from a Christian perspective. All we ask of you is for an open-minded and willing attitude towards Christian teachings.
2. Unfortunately, our program is not able to accommodate those individuals who require psychiatric medications such as antidepressants, anti-anxiety, mood stabilizers, etc.
3. We are a non-smoking program. Nicotine is a highly addictive drug and we recognize its negative impact on your overall health and well-being. You may use nicotine replacement therapies during the first 30 days of the program, but must be nicotine-free before phasing into the program.
4. We are a time-out from romantic relationships (with the exception of a legal marriage, which is a separate issue).
5. Because our program is designed for those who have no other resources, those accepted into the program are not allowed to accept any outside income (such as SSI, SSDI, Unemployment, GA, etc.) while in the program.
6. The program can accommodate up to 14 women. Space is limited and so we do have guidelines on the amount of items you can bring into the program. More information on this will be provided upon your acceptance.

More than anything- we want you to succeed in your recovery! If you have questions about any of the above, we encourage you to call Becky Hays or Deborah Paukowic at 707-576-1471 or by email at dpaukowic@srmission.org.

Please fill out the following application honestly and thoroughly. Also, include a cover letter telling us about yourself and how your drinking/using has affected your life. Most importantly- please include a contact phone number and a contact address so that we may follow-up with you in a timely manner.

We believe in the Bible and in Jesus Christ. Our policies are designed around these beliefs. While you do not have to be a Christian to enter our program, we do ask that you are open to Christian teachings.