Shane's Crib Application
Still Water's Outreach (Douglas Campus)
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We are a Christian, Spirit-filled, Discipleship program that also uses recovery tools and education.  We believe in Jesus Christ as our Savior and use the Holy Bible.  We attend Bible study groups, do a daily devotion, attend church twice weekly, and only listen to Christian music.  We believe in laying on of hands, anointing with oil, and walking through deliverance of hurts, hang ups, and habits thru the guidance of Holy Spirit.  We are non-denominational, but our home church is a Church of God (Pentecostal).  Our focus is on building a relationship with Jesus and learning how to live a victorious life in recovery.  You may experience these Biblical/Spiritual Principles while in this program. *
Required
On occasion, you will be given an opportunity to work at banquets, weddings, or for catered events at Still Waters.  For any of these things you will be paid minimum wage.
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Required
You will be a part of the Frontline Warriors traveling ministry team.  The Frontline Warriors travel to different churches and minister using praise dance, songs, and testimonies.  You will be required to participate somehow in this ministry.  Everyone has a part, no matter how small or how big.
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Required
No romantic, physical, or emotional relationships for 12 months unless you are married and it’s a healthy relationship.  You must agree to completely investing in your recovery for 12 months, and not let any distractions from significant others interfere.
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Required
Dental and medical needs will be your responsibility.  We will not pay for your dental or medical needs.  This will need to be paid by your family, or it will be taken out of your income while in the program.
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Required
The only piercings allowed are your ears, and your hair must be a natural color.
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Required
Cell phones and vehicles are only allowed at 9 months in the third phase of program.
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Required
We are not a medical facility, and we do not accept residents with mental medicines.  Approved antidepressants will be determined case-by-case.  
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Required
There will be no alcohol, drug, or nicotine use while in the program.  No use on home passes either.
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Required
Name: First and last *
Email *
Address *
City
State *
Zip Code *
Primary Contact Phone Number *
Assigned Gender at Birth
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Age *
Race *
Height *
Weight *
Do You Snore or Talk in Your Sleep? If yes, which one is it?
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Social Security Number *
Birthday *
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Sexual Orientation *
Marital Status *
Spouse's Name
Number of Dependent Children *
Level of Education *
Emergency Contact Person *
Relationship to Applicant *
Emergency Contact Address *
Emergency Contact Phone Number *
Do you attend church? *
What church do you attend?
Do you have medical insurance? *
Occupation *
Date of last employment *
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Do you receive any of the following? *
Required
Are you required to pay child support? If so, how much and where? Do you have someone who is willing to pay your child while you are in treatment? If so, what is their name and contact information:
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How many years have you been using drugs?
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What is your drug of choice? *
What Drugs/Alcohol are you using now?  
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Do You have a history of intravenous use?
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When was the last time you used drugs or alcohol?
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How many treatment facilities have you attended? Please list the facilities that you attended.
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Which Programs did you complete?
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Have you ever been diagnosed with a mental health condition?
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If you have been diagnosed with a mental health condition, what was the diagnosis?
Are you currently taking any mental health medications?
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If you are taking mental health medications or any other medications, what are they?
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Do you have any food allergies?  If so, please list:
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Date of last physical? *
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Will someone be financing your medical needs?  If yes please name them and a phone number they can be reached.
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Have you ever had, or do you currently have any of the following?  If you give us false information on your current health or history, you can be dismissed from the program.
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Required
Please rate your Dental Health 1-10 (1 Being Healthy 10 Being mostly Broken/Rotten) Give Explanation.
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Healthy
Broken/needs work
Do you currently have or have you ever had issues with Bulimia or Anorexia?  
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Are you pregnant?
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Have you ever attempted suicide?
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Have you ever been arrested?
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If you have been arrested, how many times?
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Are you on any of the following?
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Required
Are you mandated to complete a recovery program?
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If yes to above question, what are the names, addresses and telephone numbers of your probation/parole officers?
Have you ever been convicted of a violent crime?
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Are you a registered sex offender?
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Do you have any pending charges?
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If you have pending charges, what are they?
Do you smoke cigarettes?
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Shane's Crib is a non smoking program. Are you committed to NOT smoking during your stay here?
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How would you rate your Physical Condition?
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Poor
Excellent
How would you rate your Mental Condition?
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Poor
Excellent
How would you rate your Emotional Condition?
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Poor
Excellent
How would you rate your Spiritual Condition?
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Poor
Excellent
Do you admit that you are powerless over drugs and alcohol and that your life has become unmanageable?
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All payments are non-refundable. There is a one-time entry fee of $600, and rent is $230 per week.  After 3 to 6 months of treatment, resident will pursue full-time employment. Entry fee is required prior to or on the day of arrival in the form of cash, cashier’s check, or money order.  Entry fee and first 12 weeks of rent can be paid by approved third parties to offset cost of program.  
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Required
I accept and agree that I am financially responsible for my own personal needs such as personal hygiene
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Required
Any medical, dental, or etc. will be my sole responsibility either through private pay or through my private insurance company. This includes the cost of all prescribed medication and/ or medical supplies. NO EXCEPTIONS
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Required
In filling out an application for entry into Shane’s Crib, we ask that you write a letter of motivation, stating why you feel as though you want help at this time. 
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