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573-248-6323 | 1732 Hope St, Hannibal, MO
HARVEST OUTREACH MINISTRIES
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Sober Living Programs
Loaves and Fishes Program
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Please complete
both
pages of this application.
Application for Membership in
The Harvest House
Name:
*
D.O.C. Number
*
Gender (check box that applies)
*
Male
Female
Date of Birth
*
Phone Number where you can be reached:
*
Present Address
*
Check if this address is a treatment center or D.O.C.
Are you an alcoholic?
*
Yes
No
Date of Last Drink:
Are you an Addict?
*
Yes
No
Date of Last Use:
List drugs you use addictively:
Do you want to stop using drugs and alcohol?
*
yes
no
How many AA/NA or other meetings do you attend a week?
*
Do you have a sponsor?
*
Yes
No
Will you attend church services?
*
Yes
No
If "No," please explain. If "Yes," do you already have a church?
*
Are you employed?
*
Yes
No
If "Yes," who is your employer?
Are you getting disability or other non-job related income
*
Yes
No
If "Yes," what?
What is your income right now?
*
What do you expect your income to be next month?
*
Do you have a medical doctor?
*
Yes
No
Name of Provider:
Phone Number of Provider's Office:
Do you have a mental health provider?
*
Yes
No
Name of Provider:
Phone Number of Provider's Office:
Do you take prescription drugs?
*
Yes
No
If "Yes," list drugs and the reason the drug was prescribed:
Have you ever been in a treatment facility for drug/alcohol addiction?
*
Yes
No
How many?
If you are currently in treatment, please list the facility:
Name of Provider:
Name of Counselor:
Phone Number:
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Home
Sober Living Programs
Loaves and Fishes Program
Apply
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