Eligibility Form | Women's Care Center

The eligibility form should be completed before submitting the full application. If you have any questions, please contact the Center.

First name

Middle Name

Last name

Birthday

Month

Day

Year

Phone

Address

Have you ever been convicted of a violent crime (assault charge)?

Are you currently taking prescribed medications of narcotics or controlled substances?

We are a Christian-based facility. Will you have any issues with attending Bible classes and church?

We are a no-smoking facility. Will you have any issues agreeing to this policy?

No cell phone use during your phase program which is 6-9 months. After 30 days you will earn once-a-week phone calls in the manager's office. Will you have an issue with this policy?

Approved visitors are allowed the first Sunday of each month after your first 30 days. Will you have an issue following this policy?

Will you have an issue giving up your freedom for a short time to concentrate on yourself, your healing, your spiritual growth, and your sobriety?

Part of our program requires you to clean, cook, and do household chores. Do you have any limitations that would hinder you in this area?

Do you have any medical problems that hinder your day to day activities?

If yes, please list your diagnoses, treatment and your limitations due to your illness.

Our program is to heal from addiction, hurts, habits or hangups and this is not a homeless shelter? Is this the type of facility you are looking for?

Since our program is focused on healing, you will not be allowed to work until you complete the program. Will this be an issue for you?

The fee is $500 deposit and $100 weekly. Do you have anyone that can sponsor you?

Will you need to apply for a scholarship until you graduate?

After you graduate you may apply to live at the Center for another six months while you work and save. The fee for this is $150 per week. Is this something you might be interested in?

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