Your Name (Last, Middle, First):
Phone: Email:

LifeChange is a Christ-centered addiction recovery community. When you enter LifeChange you live and work with a community of people committed to transforming their lives and breaking free of addiction.  LifeChange is not a clinical treatment facility or a “program” or a series of steps. It is a community of people helping each other and supporting each other to reach beyond maintaining sobriety to a transformed and abundant life.

AUTHORIZATION OF RELEASE OF INFORMATION

I hereby give my permission and consent to any and all persons or entities to relase and receive information to Union Gospel Mission, 3 NW Third Ave., Portland, Oregon 97209, concerning any of my personal information, substance abuse history, treatment history, criminal history, medical history, educational records or family background.

Resident's Name: By Checking Here Authorize the release of information Date:

APPLICATION PROCESS

  1. FILL OUT THIS APPLICATION COMPLETELY and return it to:
    Union Gospel Mission, 3 NW Third Ave., Portland, Oregon 97209
  2. ATTEND ALL INTERVIEWS.
    Be prompt and comply with all requests including DRUG TESTING.
  3. This process may take several days, and the interviews serveral hours.
    A criminal history check will be procured by Union Gospel Mission.
PERSONAL INFORMATION
Your Name (Last, Middle, First)
Social Security Number: Date of Birth:
SUBSTANCE ABUSE INFORMATION
Drugs Used Years Used

  1.

  2.

  3.
Why do you need LifeChange?
TREATMENT HISTORY
List Recovery Programs you've been in most recently, the dates you were there, whether you completed the program and, if not, why?
Date: Program: Completed? Why?
  1.
  2.
  3.
Have you been in any other programs? - Yes - No
How Many?
Do You Have a Valid Drivers License?    Yes - ,    No -
If no, Why?
MEDICAL HISTORY
PHYSICIANS CARE
Do you have a medical card? Yes -    No -
Are you currently under the care of a physician? Yes - ,    No -
If so, list physician:
Name:   Phone:
Address:
Are you being treated for a current condition?
If Yes, what is the condition?
Have you ever been hospitalized? Yes - , No -
If Yes, What for?
Do you currently have a toothache? Yes - , No - Do you wear glasses? Yes - , No -
Note: While in LifeChange, you will be financially responsible for all your own medical costs. If you do not have medical insurance you may qualify for Oregon Health Plan. Union Gospel Mission does not charge a medical fee for LifeChange recovery services.
MEDICATIONS OR PRESCRIPTIONS
Are you taking any form of medication of prescription? Yes - ,    No -
If so, list the medication or prescription: 1. -    2 -
PHYSICAL CONDITION
Are you currently detoxing? Yes - ,    No -
Do you have any allergies? Yes - ,    No -
What is the allergy? -
Explain details of the allergy:
Are you able to lift 50 pounds? Yes - ,    No -
If no, explain why:
WOMEN
To your knowledge are you currently pregnant? Yes - ,    No -
PSYCHIATRIC CARE
Are you currently under the care of a psychiatrist / psychoanalyst? Yes ,    No
If yes, list caregiver - Name:    Phone:
Caregiver Address:
List condition caregiver is treating:
CRIMINAL HISTORY
List the most recent arrests by date and the reason for the arrest.
Date: (Month/Year) Reason: County: State:
1.
2.
3.
Do you have other arrests on your record? Yes - ,    No - , If yes, how many
List most recent convictions by date and sentence given.
Date: (Month/Year) Crime Convicted of : Sentence Received : County/State:
1.
2.
3.
Do you have other convictions? Yes - ,    No - , If yes, how many
List most recent jail or prison time by date and institution.
From: (Month/Year) To: (Month/Year) Institution: Address/County:
1.
2.
3.
Do you have time served on your record? Yes - ,    No -
Are you currently on parole or probation? Yes - ,    No -
If so, Bench/ PO What Court/Office: Name of Judge/PO/County:
1.
2.
Do you have other outstanding warrents? Yes - , No - ,   If so, how many?
Where?
WORK HISTORY
List your three most recent jobs by date, employer and why you left.
From: (Month/Year) To: (Month/Year) Employer: Address:
1.
Reason for Leaving:
2.
Reason for Leaving:
3.
Reason for Leaving:
ACTIVE JOB RELATED CLAIMS
While in LifeChange you will not be allowed to file any new claims.
You must designate the LifeChange trustee as your payee.
You must place in trust all claims paid until you exit LifeChange.
Do you currently have an active claim for Workers Comp., Unemployment Insurance or Disability? Yes - , No -
INACTIVE JOB-RELATED CLAIMS
Have you ever made a claim (now closed) for Workers Compensation Unemployment Insurance or Disability? Yes - , No -
If yes, how many have you made?
What type of claims were they?
What was the result of each claim?
EDUCATIONAL HISTORY
High School
Have you graduated from high school? Yes - , No -     If yes, When -
If yes, what school?
Name of school City County State
If no, what grade did you complete?
Have you taken the GED? Yes - , No -
Did you pass? Yes - , No -
If yes, where and when?
OTHER SCHOOLS
Have you completed any trade or vocational school? Yes - , No -
If yes, what school?
Name of school City County State
Have you completed any others? Yes - , No -
If yes, what school?
Name of school City County State
Have you ever enrolled in any other schools without completing? Yes - , No -
If yes, what school?
Name of school City County State
PROPERTY ASSETS

LifeChange allows you to bring NO Personal Property into the community (other than your wallet) and no clothing (other than the clothes you wear when you enter). You must store all of your possessions outside the Union Gospel Mission.

LifeChange allows you to bring NO MONEY, assets or valuables into the community. Union Gospel Mission will provide you , if needed, a legal trustee to protect your money and assets from dissipation while you are in LifeChange. Any person receiving passive income or entitlements must designate the trustee as payee of those benefits (to be placed in trust). If you leave before successfully completing LifeChange, then you have thirty days to claim your personal belongings that are on your inventory sheet in your file.

Do you have money/assets to place in trust if you enter LifeChange? Yes - , No -
Are you receiving any entitlements (SSI, Disability, etc.)? Yes - , No -
Are you willing to designate the trustee as your payee? Yes - , No -
Do you expect to receive any monies, settlements of assets while you are in the LifeChange community? Yes - , No -
If so, what is the source of the monies?
What is the amount you expect to receive?
FAMILY HISTORY
Family Origins
Parents:
Mother Father
Address Address
City & State Zip           Phone City & State Zip           Phone
MARRIAGE / CHILDREN
Are you currrently married? Yes - , No -
If yes,
Name of Spouse
Address City & State Zip
Do you have living children? Yes - , No -
If Yes:
           
Name of Child - Age Name of Child - Age
Guardian of Child Guardian of Child
Address of Child Address of Child
Phone of Child Guardian Phone of Child Guardian
Are these children under CSD supervision?
If yes:
           
Name of Caseworker - Phone Name of Caseworker - Phone
Name of Child Name of Child
Address of Child Address of Child
Phone of Guardian Phone of Guardian
THE LifeChange PROMISE

I need LifeChange because I have serious, life controling problems.
During LifeChange I agree to the following:
1. Cash I need to, and will, live without cash.
2. Alcohol/Drugs I need to, and will, live alcohol and drug free.
3. Relationships. I need to, and will, recover without conflicting relationships.
4. Possessions. I need to, and will, live with rules restricting my possessions.
5. Existing. I need to, and will, live with rules restricting my travel.
6. Threats I need to, and will, make no threats or acts of violence.
7. I give my word that I will live by these and all of the other LifeChange rules.
By checking this box I agree to the above terms -      Name -
I further understand that under no circumstance can Union Gospel Mission be under any obligation to me; and that I am a beneficiary and not an employee of the Mission and LifeChange. I understand that my admission and continued residence in LifeChange is dependent upon my need for recovery, life skills training, work therapy and spiritual growth that LifeChange provides. My willingness to trust God, grow spiritually and help others in LifeChange, including my voluntary performance of such duties as are assigned to me, is important for my recovery, and eventual completion of the LifeChange program.
By checking this box I agree to the above terms -      Name -
WAIVER OF WAGES, WORKERS COMPENSATION AND UGM LIABILITY

I understand that LifeChange will provide me work therapy and job training. I agree that I am working voluntarily as part of my recovery without any wages being owed or paid to me. I also understand that I will not have any workers compensation coverage. I agree to remain liable for all of my own medical treatment, and I hereby release Union Gospel Mission or LifeChange that I may claim.
By checking this box I agree to the above terms -      Name -
PERMISSION TO USE PHOTOGRAPH, VIDEO OR STORY:
I grant Union Gospel Mission my permission to take and use a photograph or video recording of me, and to distribute that photograph or recording as they deem fit, publicly. Union Gospel Mission may also use my name and information about my life in the promotion of Union Gospel Mission or LifeChange as they deem fit. I release any and all claims that such photograph, recording or information about me violates any right to privacy I may have.
By checking this box I agree to the above terms -      Name -
INSPECTION OF PERSONAL MAIL AND COMMUNICATION RIGHTS WAIVER:
I grant Union Gospel Mission my permission to open and inspect mail sent to me while I reside in LifeChange. I also understand that I will be subject to a communication ban that will restrict my ability to talk or correspond with any other or all persons designated by LifeChange leadership for a period of time.
By checking this box I agree to the above terms -      Name -
UNION GOSPEL MISSION-LIFECHANGE
ADMISSIONS MEDICAL
QUESTIONNAIRE
YES - , NO -

1. Can you life heavy objects? What is your limitation? Explain:
YES - , NO -

2. Have you ever had a neck/back injury? Explain:
YES - , NO -

3. Do you require medical attention or medication? If so, What is the nature? Explain:
YES - , NO -

4. Do you have any of these communicable diseases?

- Tuberculosis - Venereal Disease
- Hepatitis - None
Other (Specify):
If you have Hepatitis C, What stage are you in?
YES - , NO -

5. Have menstrual cramps severe enough to limit your activities at any time during the month? Explain:
YES - , NO -

6. Do you have a history of heart or cartiovascular problems? (i.e. high blood pressure, heart murmur, etc.) Explain:
YES - , NO -

7. Do you have lung or pulmonary system limitations? (i.e. asthma, emphysema, etc.) Explain:
YES - , NO -

8. Do you have bone, joint or muscle limitiations? Explain:
YES - , NO -

9. Would you submit to a test for the H.I.V. Virus?
YES - , NO -

This is a voluntary question and confidential information; have you ever been tested for the H.I.V. Virus?
YES - , NO -

Would you be willing to disclose the results.

Positive / Negative
(if you are H.I.V. positive and are presently taking medications this could result in further discussion.)

YES - , NO -

12. Do you have or ever had an eating disorder? Explain:
YES - , NO -

13. Is there any reason that you cannot physically participate in the LifeChange program? Explain:
YES - , NO - 14. Have you ever been diagnosed with cancer?
YES - , NO - 15. Do you currently have cancer?
YES - , NO - 16. Are you a late stage alcoholic?

The answers on this questionnaire are true and correct to the best of my knowledge. Any false and / or misleading information could cause for termination or referral from the LifeChange program. Furthermore I will not hold the LifeChange program liable for any preexisting medical condition that I might have. If I am in need of outside medical condition that I might have.

  1. Be required to pay for that care via my own resources.
  2. Be referred from the program if it is determined that my medical condition interferes with my treatment.
Furthermore as a part of my admission process, I agree to have a history and physical examination and screened for TB.

By putting your name here you are agreeing to the statements in this form.

Your Name:    Date:

Name of Witness:   Date:
Name of Witness:   Date:


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