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318.582.5757

Testimonials
Recovery Program
- Intake Form
Thrift Store
FAQ
Contact

Testimonials
Recovery Program
- Intake Form
Thrift Store
FAQ
Contact

Intake Form

Interested in joining our program?

Ladies Recovery Intake Form

Fill out this form if you are interested in yourself or your loved one becoming part of our ladies recovery program.

"*" indicates required fields

Step 1 of 8

12%

First Name

Last Name

Date of Birth

MM slash DD slash YYYY

Email

Phone

Address

Street Address City State ZIP Code

Criminal Background

Probation

Parole

Sex Offender

Pending Charges

N/A

Explain Any Pending Legal Issues & Upcoming Court Dates In Detail

Addiction Information

Alcoholic

Yes

No

Date Last Used

MM slash DD slash YYYY

Addict

Yes

No

Date Last Used

MM slash DD slash YYYY

1st Drug of Choice

How Long Used?

2nd Drug of Choice

How Long Used?

Emergency Contact Information

A Relative Not Currently Living with You

Name

Relationship

Phone

Email

Address

Street Address City State ZIP Code

Spouse Information

If Married

Name

Are You Able To Talk With Your Spouse?

Yes

No

Cell Number

Work Phone Number

Medical Information

Are You Pregnant?

Yes

No

If Pregnant, How Many Weeks?

Current Medications

Vehicle Information

Own Vehicle?

Yes

No

License Plate Number

Is Vehicle Insured:

Yes

No

Current Driver's License

Yes

No

Children's Names

If overnight privileges are desired

Name

Age

Column 3

Drug & Alcohol Policy

Consent*

Agree*

I authorize and give full permission to have Transformations Ladies Recovery Program and/or their selected physician send a specimen of my urine and/or blood for a screening test for the presence of illegal drugs, alcohol, tobacco or prescription medication taken without a prescription.

I will hold all parties concerned harmless, meaning I will not sue or hold responsible for any alleged harm to me or interfering with my obtaining a job or continuing employment due to not submitting to the tests or as a result of the report of the test. This includes but is not limited to possible clerical or laboratory error.

I understand that Transformations will require a drug screen test at random. My refusal to drug test or a positive result will be grounds for termination from the Transformations Ladies Recovery Program.

Release of Criminal Conviction Records

Applicant’s Name

Address

Street Address City State ZIP Code

Drug Screen Authorization & Consent

Consent*

Agree*

I authorize and give full permission to have Transformations Ladies Recovery Program and/or their selected physician send a specimen of my urine and/or blood for a screening test for the presence of illegal drugs, alcohol, tobacco or prescription medication taken without a prescription.

I will hold all parties concerned harmless, meaning I will not sue or hold responsible for any alleged harm to me or interfering with my obtaining a job or continuing employment due to not submitting to the tests or as a result of the report of the test. This includes but is not limited to possible clerical or laboratory error.

I understand that Transformations will require a drug screen test at random. My refusal to drug test or a positive result will be grounds for termination from the Transformations Ladies Recovery Program.

Authorization For Release of Health Information

Name

Address

Street Address City State ZIP Code

Family Contacts

Name

Relationship

Phone

Email

Name

Relationship

Phone

Email

Name

Relationship

Phone

Email

Visitors List

Only ten people can be on a resident’s visitors list. Each visitor must be interviewed and approved by the Transformations program director(s) and/or house manager before any visit. Each visitor must also attend a Visitor’s Orientation session held at White’s Ferry Road Church at 9:00am (during Bible class) on the second Sunday of each month in the A-Wing Prayer Room. Family visits will take place after church in the White’s Ferry Road Outreach Center from 11:30am to 1:00pm on the same second Sunday. All requests for visits must be made in writing to the house manager and program directors at least seven days in advance. Turning in a request does not result in automatic approval.

Name

Relationship

Address

Street Address City State ZIP Code

Email

Phone

Second Vistor

Name

Relationship

Address

Street Address City State ZIP Code

Email

Phone

Third Vistor

Name

Relationship

Address

Street Address City State ZIP Code

Email

Phone

Transformations Ministries Resident Intake Inventory

SHIRTS MUST COVER THE STOMACH AND BACK, TANK TOPS OR SPAGHETTI STRAP TOPS MAY BE WORN UNDER SHIRTS ONLY, NOT ALONE; NO LOW-CUT SHIRTS OR DRESSES MAY BE WORN; SHORTS MUST HAVE A MINIMUM OF A 6” INSEAM; SKIRTS AND DRESSES MAY BE NO MORE THAN 2” ABOVE THE KNEE.

Filling out an application does not guarantee entry into the program

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318.582.5757

1200 Arkansas Rd.
West Monroe, LA 71291
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Saturday 9am - 4pm
Sun & Mon Closed
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