Her Turning Point
Application for Residency
Please answer all questions accurately and correctly. Please do not leave any blanks on your application,
as this will delay processing. Please write “N/A” or strike through any sections that do not apply. Her
Turning Point reserves the right to deny any application entrance to the program.
Information about You
Date__________ Name__________________________________ Name you go by_________________
Present Address_______________________________________________________________________
City_______________________________State_________Zip___________________County__________
Home Telephone______________________ Cell____________________ Date of Birth_______________
Age_________ Race________________ Social Security Number___ ___ ___- ___ ___- ___ ___ ___ ___
Physical Characteristics:
Height__________ Weight__________ Eye Color__________ Hair Color__________
I am currently Single _____ Married_____ Separated _____ living with someone _____
Do you have any children? _____YES _____ NO – If yes, how many? _____
Child 1- Name ______________________________ Gender____________ Age _________
Child 2- Name ______________________________ Gender____________ Age_________
Child 3- Name ______________________________ Gender____________ Age_________
Highest grade completed? __________ Do you need to work on a GED? __________________________
Have you ever applied for admission to Her Turning Point Home or were you a previous resident?
Yes_____ No _____ If yes, when? _________________________________________________________
Why would you like to come to Her Turning Point?
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What would you like to see happen in your life during your stay?
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How did you hear about Her Turning Point?
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What is the reason that you cannot stay with a family member?
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For office Use Only
Date Received: _________
Accepted Yes ______ No _____
Comments:____________________________________________________________________________
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Pregnancy
Are you pregnant? Yes_____ No_____ Approximate Due Date __________________________________
Has a doctor confirmed your pregnancy? Yes _____ No _____ (Please mark one “X”)
Mental Health History
Please circle below, if you have experienced or been treated for the following:
Psychological issues – depression, anxiety, bi-polar, thought disorders, hallucinations, and personality
disorders
Suicidal thoughts or attempts
Reoccurring injuries requiring medical treatment
Hospitalization (major surgery, overdoes, etc.)
Taking medication as prescribed by doctor – please list medication (s), dosage and reason for taking
medication in the space provided below.
Eating Disorders
Received disability payment s
Please provide an explanation for anything circled above
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Counseling
Have you ever been diagnosed or treated for: DID/Dissociative Disorder_____ ADD _____ ADHD _____
Schizophrenia _____ Bi-Polar Disorder _____ Borderline Personality Disorder _____
Have you ever self-mutilated? Yes _____ No _____ How? ______________________________________
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Have you ever been to counseling? ______
Facilities/Persons_______________________________________________________________________
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Have you ever received psychiatric care or been in a psychiatric hospital? Yes_____ No _____
Date of Entry
Program Name
City/State
Reason for Leaving
Date of Discharge
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Medical
Do you have any allergies? List:
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Medications
Please list all current medications that you take:
Medication
Dosage
Reason
For How Long
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If you have been prescribed medications, please do not stop them on your own, but continue to take
them as prescribed by your physician (s). Her Turning Point is not a medical facility and therefore does
not admit individuals who need Psychotropic drugs or narcotics. We will require a statement from the
doctor/psychiatrist/specialist who prescribed your medication fully explaining the need for this (these)
prescriptions.
Legal History
Have you ever been arrested/incarcerated? Yes _____ No _____ If yes, how many times? __________
Please explain reason for arrest/incarceration:
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Have you ever been convicted for the following (please circle all that apply)
Arson
Assault
Sexual Offense
Violent Crime
Domestic Violence
Please provide a brief explanation for any items that were circled above.
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Do you have any outstanding warrants? Yes______ No _____ If yes, how many? _____
Please explain the warrant: (County, issue, amount of fees etc.)
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County Warrant Issued In: ___________________________ City ___________________ State ________
Do you have any pending court dates? __________ Explain: ___________________________________
Name of Legal Representative: _______________________________________Phone: ______________
Judge’s Name: ________________________________ Court _________________ County ___________
Have you ever been on probation or parole? _________ Are you now? ___________________________
How long? _______________________________ Length of time remaining? ______________________
How often do you report? _________________________ In person or through mail? ________________
Name of probation or parole officer: _______________________________________________________
Address: _____________________________________________________________________________
County: ________________________________ Phone: _______________________________________
Chemical Dependency History
1: Drug (s) of choice used in the last 12 months ______________________________________________
2: At what age did you begin using alcohol/drugs? __________________________________________
3: How often do you drink alcohol or use drugs? _____________________________________________
4: How long have you realized that drugs and/or alcohol are problematic? _______________________
5: When did you last use? Alcohol ______________________ Drugs ____________________________
6: How much do you consume at one time? Alcohol __________________Drugs __________________
7: Do most of your social activities involve drug/alcohol use? Yes ______ No______
8: Have drugs/alcohol effected your ability to hold a job? Yes ______ No _______
9: Are you presently in treatment? Yes _____ No_______
10: Have you ever been in an alcohol, drug, or detoxification program before? __________ (if yes,
please list facilities)
Name of Facility
Length of Stay
Completed
Year
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Sources of income
Please enter all that apply
Welfare Amount $__________
Social Security Amount $_________
Child Support Amount $__________
Disability Amount $__________
Employment – Employer’s Name: ____________________Hourly Rate $____________
Food Stamps Amount $ __________
Other Income Sources
Sponsorship – Please indicate any income that could be used to offset Her Turning Point Fees.
Individual/friends/churches Amount $_______________
In completing this application & by initialing after each statement, acknowledge…….
1. I acknowledge that Her Turning Point is a Christian-based facility and as a result, I will be
required to attend church service at least one time a week, attend prayer meetings, and
participate in Bible studies, Celebrate Recovery and Chapel services.
Initials________________
2. I acknowledge that I must commit to working a highly disciplined spiritual program for the
next 12 months, once admitted into Turning Points program.
Initials________________
3. I acknowledge that Her Turning Point does not permit the use of alcohol, drugs or tobacco to
be used while in the program at Her Turning Point. If I am using any of these substances while
in the program, I acknowledge that I will be subject to discharge from Her Turning Point.
Initials_______________
4. I acknowledge that Her Turning Point has a strict dress code policy, which requires I must be
appropriately dressed and groomed at all times.
Initials_______________
5. I agree to submit to the rules, regulations, and policies of Her Turning Point authorities and
am willing to allow Christ to change my life.
Initials_______________
6. I acknowledge that Her Turning Point, will conduct periodic drug test/screens and
acknowledge that a positive result may result in IMMEDIATE discharge from Her Turning Point
and notification as required by law to my probation/parole officer, if one is assigned.
Initials_______________
7. I acknowledge that Her Turning Point is NOT RESPONSIBLE for my medical needs or attention,
loss due to theft or transportation to non-program related venues.
Initials_______________
8. I hereby authorize Her Turning Point to conduct a police background check
Initials_______________
9. I hereby authorize Her Turning Point to talk with individuals who previously provide
treatment to me, including but not limited to, my doctor or former hospitals, clinics, or other
health/mental care facilities to discuss any treatment received under their care.
Initials_______________
10. I acknowledge that. Her Turning Point / City of Refuge Hope Center / Mr. Kocher are NOT
RESPONSIBLE for ANY accidents that happen at 103 West Broadway West Harrison Indiana. If
any accident should happen to me/children I am to turn it in on my own insurance, I am FULLY
RESPONSIBLE.
Initials___________
11. Notice, it is hereby understood that Her Turning Point/ City of Refuge Hope Center/ Mr.
Kocher are not responsible for any personal property left, lost or stolen while in the program. I
agree that any property or money left at Her Turning Point over 14 days from my departure
date, voluntarily or not, announced or unannounced becomes the property of Her Turning
Point. I also understand that if I am dismissed from Her Turning Point or decide to leave the
program I must leave within 24 hours. If I become belligerent, abusive, uncooperative, or
threatening I must leave the facility immediately. It is important that medical, dental, business
and legal needs be taken care of before entering the Her Turning Point program. If you have
such needs that cannot be taken care of before entering Her Turning Point please call the
center and explain your situation.
Initials____________
12. Her Turning Point are committed to helping students become physically, mentally and
spiritually whole. We are not, however, a medical program. We will endeavor to assist you in
securing whatever medical help we can while you are in the program. If you become ill or
need medical attention once you are in the program we will assist in connecting you with a
medical facility. You are responsible for any fees that accrue in connection with your visit to or
treatment from any medical facility. We do not financially assist students in meet in their
medical bills
Initials_____________
I, ________________________________________________________________, acknowledge that
to the best of my knowledge, I have proved true and accurate information in this application.
Furthermore, I authorize Her Turning Point to verify the validity of this application and any
information contained herein. I further give Her Turning Point staff authorization to communicate
with my support network to determine eligibility for admission. I also authorize Her Turning Point to
speak with my representation, legal or otherwise, to assist with admission, recovery or aftercare. I
understand that any false or misleading information could result in a denial for admission or a
discharge from the program.
Sinature______________________________________________Date:___________________________
Witness______________________________________________Date:____________________________
State of________________________
County of_______________________
On this, the________ day of __________, 20____, before me a notary public, the
undersigned officer, personally appeared________________, known to me (or
satisfactorily proven) to be the person whose name is subscribed to the within
instrument, and acknowledged that he executed the same for the purposes
therein contained.
In witness hereof, I hereunto set my hand and official seal.
Notary Public_____________________________________
Date_____________________________________________