Application For Participation in the RLM Program

Reviving Lives Ministries of New Bern, Inc. (RLM) carries a faith-based solution for addiction to people who are
willing to change, who need a stable home, wellness skills, and connection to community.
email: Director@revivinglivesministries.org or Fax: : 1-888-728-6106

Personal Information:

Name: ________________________________ Date of birth: ___________ Gender:_____________

Current detox facility: _______________________________________________________________

Are you experiencing homelessness: ___________________________________________________

Home address:________________________________________________________________________

_____________________________________________________________ Phone: _______________

Marital Status: Single _________ Married ________ Separated ________ Divorced _________

Resident of: Racial Affiliation: Income:

African American
Craven County Non Latino Below $15,000

Pamlico County American Indian $15,000-$24,999

Jones County Asian American $25,000-$34,999

Carteret County Caucasian Non Latino $35,000-$49,999

Other Other Over $50,000

Have you ever attended/lived in a residential, detox or other substance abuse

program/placement before? Yes/No Where/When?

_______________________________________________________________________________________

_______________________________________________________________________________________

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What are your major concerns about (Check any that apply):

Alcohol use ____ Illegal drug use _____ Prescription drug use_____ Relationship(s) ____

Physical Health ____ Mental Health ____ Finances ____ Other concerns ____

Your Drug(s) of Choice: ___________________ At what age did you start using: ___________

When did using substances start causing problems in your life: ________________________

_______________________________________________________________________________________

Date of last Drug/Alcohol Use: ______________________

Financial Status and Strengths Information:

Do you have access to financial support from family (if needed)? ________________________

What services or benefits do you receive (check any that apply):

VR_____Medicaid_____Medicare_____Welfare______SSI______SSDI_____VA_____Other_____

Applying for disability? Yes _____ No _____ Will you in the future? Yes _____ No _____

Highest level of education: __________ Financial Savings: ____________

Supportive relationship with a friends or family member: ____________

Circle any of the following qualities that you have or had in the past:

Motivated Willing Cooperative Devoted Enthusiastic Flexible

Hard working Open minded Realistic Reliable Self-disciplined

Calm Capable Polite Creative Curious Empathetic Helpful

Kind Neat Patient Sociable Humble Adaptable Good Humor

Types of jobs have you had in the past: ________________________________________________

_______________________________________________________________________________________

Important Information:

During your first 2 - 3 months of our program, you are required ride a bike to get to
Intensive Outpatient classes about substance use disorders and how to cope. You cannot
get a job until after these classes are complete.
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What family members depend on your financial support: ______________________________

Will you need to apply for scholarships for RLM program service fees: _______________

Will you require financial assistance for food and clothing: ________________________

Are you willing and able to ride a bike for 2+ miles daily: ______________________________

Legal Information:
Note: Having current or past felonies does not disqualify you from being accepted; being
dishonest about legal issues can disqualify you.

Pending or Current Charges: ________________________________________________________

_____________________________________________________________________________________

Scheduled Court Dates/County(s): __________________________________________________

_____________________________________________________________________________________

List any past charges for which you were convicted, whether served time or placed
on probation:

Do you give RLM permission to conduct a background check? Yes________ No_________

Name of Lawyer: Phone #
Address of Lawyer:
Name of Probation Officer:
Probation Address:
Phone Number:

Children
Name Age Date of Birth

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Emergency Contacts/Relationship/Addresses/Phone Numbers

Recovery Information:
Note: There are no wrong answers, we want to know what you think and feel at this
moment.

What are the biggest problems in your life right now and how do you feel (today) about a
Power greater than yourself (some call this Power, God) being able to help you overcome
the problems you’re facing?

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

What has been disappointing about your journey to recovery so far?

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

List 5 life goals 1.

2.
3.
4.
5.

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Medical Information:
Note: RLM is an abstinence-based program; we do not currently accept people who are
using Medication Assisted Treatment. RLM has other restrictions for medications such as
benzodiazepines and others. You may have to change medications upon arrival.

Make sure you list ALL medication you are taking at the present time.
List Medication mg/dosage Reason for Taking Medication

Can you: Do you:

Walk for 30 minutes Y N Have breathing problems Y N
Practice good hygiene (clean Have a history of cancer
Y N Y N
yourself well)
Climb Stairs Y N Have concerns about your anger Y N
Cook Y N Have a history of surgeries Y N
Clean Y N Have concerns about money Y N
Remember to take you meds Have concerns about another person
Y N Y N
wanting to harm you
Share a living space with 4 other Have concerns about your mental
Y N Y N
people health
Cooperate Y N Have concerns about allergies Y N
Be open-minded Y N Have concerns about sleeping Y N
Be honest about your needs and Have concerns about being away
Y N Y N
concerns with RLM staff from family for more than 6 months
Be willing to make changes to your Have concerns about past trauma
Y N Y N
life
Agree to seek therapy Y N

Tell us more about any concerns:______________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

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Traumatic Events Information:
Note: These questions are from The Adverse Childhood Experiences, or “ACEs,” quiz that
was developed in the 1990s through research conducted by the CDC and Kaiser
Permanente.

Before your 18th Birthday:

1. Did a parent or other adult in the household often or very often… a) Swear at you,
insult you, put you down, or humiliate you? or b) Act in a way that made you afraid that
you might be physically hurt? Yes or No

2. Did a parent or other adult in the household often or very often… a) Push, grab, slap,
or throw something at you? or b) Ever hit you so hard that you had marks or were
injured? Yes or No

3. Did an adult or person at least 5 years older than you ever… a) Touch or fondle you or
have you touch their body in a sexual way? or b) Attempt or actually have oral, anal, or
vaginal intercourse with you? Yes or No

4. Did you often or very often feel that … a) No one in your family loved you or thought
you were important or special? or b) Your family didn’t look out for each other, feel close
to each other, or support each other? Yes or No

5. Did you often or very often feel that … a) You didn’t have enough to eat, had to wear
dirty clothes, and had no one to protect you? or b) Your parents were too drunk or high
to take care of you or take you to the doctor if you needed it? Yes or No

6. Were your parents ever separated or divorced? Yes or No

7. Was your parent/caregiver: a) Often or very often pushed, grabbed, slapped or had
something thrown at her? or b) Sometimes, often, or very often kicked, bitten, hit with a
fist, or hit with something hard? or c) Ever repeatedly hit over at least a few minutes or
threatened with a gun or knife? Yes or No

8. Did you live with anyone who was a problem drinker or alcoholic, or who used street
drugs? Yes or No

9. Was a household member depressed or mentally ill, or did a household member

attempt suicide? Yes or No

10. Did a household member go to prison? Yes or No

Thank you for filling out this application. It may take up to three days to process. A staff
member of RLM will contact you for a phone or in-person interview as soon as possible.

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