Mercy Manor Recovery House for Women Application 

Thank you for your interest in Mercy Manor. To apply for residency, please complete the application form thoroughly by answering all required fields.

Important Application Requirements:

  1. Medical Statement: If you are currently receiving medication at a facility, you must include a medical statement with your application. This statement should list all medications you are currently taking and must be signed by the administering nurse or doctor.

  2. Mental Health and Diagnosis Statement: All applicants must provide a statement of mental health and diagnosis from a licensed healthcare provider.

What Happens Next?

Once we receive your completed application and required documents, a Mercy Manor staff member will follow up with you to schedule an intake interview. The interview can be conducted either in-person or via Zoom.

Contact Information:

Please ensure you provide your current contact information in the application. If you prefer, you may also provide the contact details for a representative who can be reached to schedule the intake interview.

We look forward to supporting you on your journey to recovery and helping you build a healthy, hopeful future.


Email *
Cannot pre-fill email
Today's date *
MM
/
DD
/
YYYY
Name of agency, institution or facility  *
Your answer
Name and title of the person making the referral *
Your answer
Contact phone number(s) *
Your answer
Name of client being referred *
Your answer
Exit Date  *
MM
/
DD
/
YYYY
Date of birth  *
Your answer
State of birth  *
Your answer
Social Security Number  *
Your answer
Please list  any of the following identification that client possesses along with ID# (below) 

-Driver's License (list number) 
-State ID
-Birth Certificate
-Social Security Card

 *
Your answer
Gender  *
Marital Status  *
Number of children (only make one selection for the total amount of children you have) *
Race/Ethnicity  *
If you have minor children, who has custody  *
Your answer
When did you start using drugs?  *
Your answer
Primary Drug(s) of choice: (select all that apply) *
What is the highest level of school completed/highest degree received? *
What types of employment have you had in the past?  *
Incarceration History and Offense: (Please describe the type(s) misdemeanor or felony, if applicable)  *
Do you have any current warrants?  *
If you have warrants, please list county(s)
If this does not apply to you please reply N/A
 *
Your answer
Are you on probation or parole?   *
If you are on probation or parole (provide your officers information. Name, phone number, email and county).
  If this does not apply to you please reply N/A
 *
Your answer
Do you have a sponsor? If yes, please provide sponsors name, phone number and how long you have had this sponsor.  *
Your answer
How long have you been sober as of today?  *
Your answer
What substance abuse and/or rehabilitation programs have you participated in? *
Your answer
Do you have insurance? If yes, what type (provide insurance number)?
If this does not apply to you please reply N/A
 *
Your answer
Do you receive any of the following benefits? 
Please select all that apply 
 *
Required
Have you been diagnosed with a physical or mental health condition? If yes, please list the condition and a list of medications you are currently taking. Please list details of physical limitations/disabilities: *
Your answer
Have you ever experienced any trauma in your life? If yes, please explain:  *
Your answer
What was your housing situation before you arrived at your current location? *
Your answer
What will be your housing situation be upon release from your current location? *
Your answer
What is your greatest need? *
Your answer
What back bills are you responsible for currently? (DMHA, AES, CenterPoint, Court Fines, etc.) 
If this does not apply to you please reply N/A
 *
Your answer
Explain what course of action will enable you to eventually live independently?  *
Your answer
What is your religious/faith belief?  *
Your answer
Do you have a source of income? If yes, what and how much do/will you receive and what is the source?  While income is not required, if you have income you will be subject to Program Fees. *
Your answer
Why do you want to come for Mercy Manor?  *
Your answer
Please name two things you have learned about yourself while in your current location:
Your answer
Please list the things you are good at doing?  *
Your answer
Please list things are you not good at doing?  *
Your answer
Who are the important/support people in your life? *
Who are the important/support people in your life? *
Who are the important/support people in your life? *
Emergency Contact Information  *
Emergency Contact Information  *
Emergency Contact Information (Name, Phone Number, Relationship to you)  *
Your answer
Visitor's List (Name, Relationship to You)  *
Your answer
Visitor's List (Name, Relationship to You) 
Your answer
Visitor's List (Name, Relationship to You) 
Your answer
This section is a consent for release of information (ROI) *
Required
Name (First, Last)  *
Your answer
Address *
Your answer
Date of Birth  *
MM
/
DD
/
YYYY
City  *
Your answer
State *
Your answer
Zip Code *
Your answer
Social Security Number  *
Your answer
I permit the release of information about myself to Mercy Manor, the agency listed above, in order that the staff of Mercy Manor might better evaluate my readiness for admission into their program *
Required
Note: I may cancel my permission at any time by informing my counselor  *
Required
Please check the information to be released about myself  (Check all that apply)  *
Required
The agency or person to release the information to is:
Mercy Manor, Inc. 
25 Grosvenor Ave. 
Dayton, OH 45417 
(937) 268-0282

 *
Required
Application acknowledgment  *
Required
Date of submission  *
MM
/
DD
/
YYYY
Get link
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report

Google Forms