Lovelady Center Entry Application
Part 1: Intake Policy: Are you a candidate to be a Lovelady Client?

Women coming from prison, jail, court ordered or DHR referrals
(released from prison or jail within the past 6 months)

Women coming from abuse or Women struggling with addiction

If she is one of the above, she must fit the following criteria:
Above the age of 22
Does not have children coming upon intake, then upon approval, no children over the age of 12
Is not more than 20 weeks pregnant
Is not on methadone or suboxone
Is not a convicted sex offender
Must be completely mobile
If disabled, must be on disability
If not disabled, must be able to hold a full-time job
If mentally disabled, must be on disability
If mentally disabled, must be able to function in large group settings, must be aware of 30 day probationary period

Email address *
Do you meet the above requirements? If not, explain why. If "yes," continue the application. *
Your answer
Have you ever been a client at The Lovelady Center? *
If you are a prior client, please explain each time you have been in our program and the circumstances around your participation and departure. Please note, if you have already completed 30/4/30, you are not eligible to return for one year since your last departure. If you have been in our program more than four times, it must be 24 months since your last departure.
Your answer
Once eligible for our Phase I program, intake fee is as follows:The intake fee is $500 for all intakes except for SRP and parole coming directly from prison. If Detox is necessary, must have $48 for medication.Must have 30 day supply for approved- medication.Intake fee MUST be paid upon intake unless coming directly from prison.All incoming clients will enter our Phase 1 program, while in Phase 1, client will be in a probationary period. Upon completion of Phase 1 with satisfactory or better participation, you will be permitted to move to Phase II. *
Once you have completed the intake policy and have confirmed you are a candidate for The Lovelady Center Program, please complete the remaining application.Thank you for your interest in The Lovelady Center Program. Individuals interested in applying for entry into The Lovelady Center Program must fill out an application completely. You may mail or fax your completed application, attention to Intake Services at the address listed above.The Lovelady Center's purpose is to help women build a strong positive foundation in Christ. Our mission statement is empowering women, through faith-based initiatives so they can return to society as well- equipped women of God. We do this by providing a safe, structured, and loving environment. We offer various classes referencing many life issues. The Residents of Lovelady Center consist of many different walks of life, needing our services for many reasons.Once Intake Services receives your Entry Application, we will process it and mail you a letter of determination stating you have been accepted, placed on the waiting list or denied. If your name is on the waiting list, it is your responsibility to contact Intake Services weekly to see if a bed is available. If we do not hear from you then your name will be removed. It is important to understand once your name is placed on the waiting list and you are contacted about an available bed, you must arrive at The Lovelady Center on the date agreed upon.If you are currently incarcerated, we will mail you an acceptance letter, however, if your release date exceeds 60 days, you will need to notify our Intake Department for an acceptance date that corresponds with your release date.Clients are required to pay an Intake Fee of $500.00 upon arrival.Children are not permitted until Phase II, and then at that time it’s only approved upon room availability. We will do our best to accommodate you and your children as soon as possible, but it could take an additional week or two once you are in Phase II. *
Name: *
Your answer
Today's Date: *
Your answer
Date of Your Birth: *
Your answer
Home Phone:
Your answer
Cell Phone:
Your answer
Alternate Phone:
Your answer
Address: *
Your answer
Marital Status:
Do you have children? *
Will they reside at The Lovelady Center with you?
(Children are not permitted until Phase II, and then at that time it’s only approved upon room availability. We will do our best to accommodate you and your children as soon as possible, but it could take an additional week or two once you are in Phase II.)Please give a brief summary of your current living situation:
Your answer
Are you currently incarcerated? *
If applicant is incarcerated, please list the names of two family members/friends of contact, their phone number, address, and relationship to the applicant:
Your answer
Legal Information: Please enter AIS Number, EOS Date, and the name & contact information for the Probation/Parole Officer, CRO, DHR Social Worker or Community Corrections Officer:
Your answer
Have you ever been convicted of a sexual offense: *
Do you have a sexual offense pending? *
Are you required by a judge to complete a program? *
If required by a judge to complete a program, List the Judge, phone number, and county:
Your answer
List all past & present felony cases that you have been arrested for in the past 5 years, the date of arrest, county & court date:
Your answer
What is your primary drug of choice and the age you first used it: *
Your answer
What is your secondary drug of choice and the age you first used it: *
Your answer
At this time, do you think you will have to detox from your current drug use? *
Please check the following medical conditions that a medical physician has diagnosed you as having: *
Required
Please list all allergies:
Your answer
Please list your physician's name and contact information:
Your answer
Are you pregnant? *
If pregnant, how many months?
Your answer
If pregnant, are you a high-risk pregnancy?
Have you received pre-natal care?
If you have received pre-natal care, who is your physician?
Your answer
Please check any of the following mental health conditions that a medical professional has diagnosed you as having: *
Required
If you checked any of the above mental health conditions, please enter your physician's name and contact information:
Your answer
Are you disabled or handicapped? *
If disabled of handicapped, please explain:
Your answer
Are you currently receiving Disability, SSI, or other funds from the government? *
Do you have Health Insurance/Medicaid/Medicare? *
List all medications that you are currently taking. All incoming clients are required to have a (30) thirty day supply of medication upon entering the Lovelady Center Program.
Your answer
I attest that the above information is true and that all medications are prescribed for the labeled purposes only and they are the only medications I am currently using.
I understand that there will be NO EXCEPTIONS allowing the use of any narcotics while I am enrolled in The Lovelady Center Program. *
Required
I understand there is a $500.00 Intake fee. I understand this fee is non-refundable. *
Required
I understand The Lovelady Center is a Faith-Based Transitional Program. I am willing to commit to a 9-12 month program. *
Required
By entering my name on this application, I agree to the above said statements and attest that all information I have provided is accurate and true to the best of my knowledge. *
Your answer
A copy of your responses will be emailed to the address you provided.
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