PROGRAM DESCRIPTION ELIGIBLE PARTICIPANTS

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MC Workshops Residential is a Christ-based reentry home for men located in Hartville, Ohio. MC Workshops Residential provides housing, board, Christian coaching and employment training for men who are re-entering society following an extended period of institutionalization.

The resident is required to sign a commitment contract agreeing to participate in all programs and events at

MC Workshops Residential for a term of 1 to 6 months. During this time, the resident agrees to follow house rules regarding behavior and to participate in all activities provided.

The resident is provided minimum wage employment during his stay and he is taught basic job skills training for future employment. Meals are prepared and served on the property and the residents are expected to attend Bible studies, go to church and participate in The Men’s Challenge program.

The resident pays a weekly sum ($125.00_{) in exchange for room and board. Finances are handled by the}

participant’s Case Manager with a weekly report showing the participant’s current financial status and accounting for all deposits and withdrawals made to the resident’s account. Ideally, when the resident leaves the program he will have a bank account, transportation, a church home, the skills needed to find a job and gain employment, an understanding of how to survive on his own and a place to live. Each resident is offered a semi private living space with a bed, dresser and writing/reading space.

The following items are provided:

 Bed and mattress

 Shelves with desk space and storage space

 Kitchen table and chairs/living room couch and chairs

 Refrigerator and microwave oven

 Personal locking food storage

 Personal belongings may be added (i.e. TV, radio), however, residents are not permitted to bring

additional furnishings. Requests to add furnishings such as storage units should be discussed with property management.

The building is a private residence and visitors are not permitted without a written request at least 7 days in advance. Any visitors will be asked to sign in and sign out. House staff will be on site 24 hours a day. Security staffing and equipment will be provided as needed. All residents are subject to random drug and alcohol testing and property searches.

ELIGIBLE PARTICIPANTS

Applicants must meet the following eligibility criteria to be considered for housing at MC Workshops

Residential. Documentation and verification must be provided.

 Adult male 18 years or older.

 Must demonstrate a need for housing and a willingness to work and learn.

 Must be a US citizen or have legal immigration status.

 Must be able to provide picture ID, and birth certificate or social security number.

 If criminal history- must submit to background check.

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MC Workshops Residential

ADULT APPLICATION

Name Date

Address

Daytime Phone

Have you ever applied before? ❏ yes ❏ no Who referred you to The Farm?

Social Security # Phone #

Driver’s License Valid? ________ HS Graduate?_____________

Age Birth date Height Weight

Occupation or Trade

Physical Problems/Special Medical Needs________________________

_________________________________________________________________________________________

Upcoming Court Dates

_________________________________________________________________________________________ _________________________________________________________________________________________

Educational Info:

Highest level of education completed?

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MC Workshops Residential

DATES SCHOOL SKILL OR TRADE LEARNED CERTIFICATE?

Medical:

HIV TEST: Y / N (circle one) Date:________ Results: Pos / Neg HEP C: Y / N (circle one) Date:________ Results: Pos / Neg

Date of last Physical: _________________ Allergies: __________________________________________________ Dental Issues:_________________________________________________________________________________ Medical Problems: ______________________________________________________________________________ Special Diet:___________________________________________________________________________________ Medication Information (include dosage):____________________________________________________________ _____________________________________________________________________________________________

Emergency Contact Info:

If you are released from our program early, you must provide us with a name and address of a family member or sponsor who will accept responsibility for you or an address where you can be dropped off. They must sign this form acknowledging that they will provide you with a place to stay when you are released.

Name Relationship

Address

Home Phone Cell Phone

I hereby acknowledge that I will accept __________________if he is released early from MC Workshops. Signature ____________________________________________ Date__________________________________

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MC Workshops Residential

THE PROBLEM

What is your main problem, as you see it?

What would improve your situation?

Is change something you look forward to?

Have you ever gone to an in-house treatment facility? ❏ yes ❏ no If yes, how many?

Which have you/do struggle with most? ❏ alcohol ❏ drugs ❏ neither

Do you smoke or use tobacco? ❏ yes ❏ no If yes, would you like to stop? ❏ yes ❏ no ❏ not really Have you ever received any form of mental health treatment? ❏ yes ❏ no If yes, please list:

DATE CLINIC REASON FOR TREATMENT OUTCOME

Do you have any special psychiatric needs? ❏ yes ❏ no What prescription drugs are you currently taking?

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MC Workshops Residential

PO Box 446, Hartville, OH 44632 • Phone 330-244-6164 • email [email protected]

FAMILY MATTERS

Parents: Name

Address

Phone

Would you say that you have a strong Christian background?

Is there anyone in your family that has experienced any of the problems that stem from alcohol or drug abuse?

Marital Status: ❏ Single ❏ Married ❏ Divorced

Do you have any children? ❏ yes ❏ no Wife’s Name

Children’s Names

Do you think that God can and will repair any damaged or strained relationships? ❏ yes ❏ no How is your prayer life? ❏ great ❏ fair ❏ poor

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MC Workshops Residential

LEGALITIES

Have you been arrested within the past 12 months? ❏ yes ❏ no If yes: Date

Arrested for

Are any of the following pending against you? Check all that apply:

❏ Arrest Warrant ❏ Court Appearance ❏ Criminal Charges ❏ Sentencing ❏ Other Briefly explain:

Do you have any upcoming court dates? ❏ yes ❏ no If yes, please list:

Are you now, or will you be under legal supervision? ❏ yes ❏ no If yes, complete the following:

❏ Probation - How long? ❏ Parole - How long?

Method of Reporting How often?

List probation/parole officers: Name

Address

Phone

If you are currently incarcerated, please provide a contact person in your jail: Name

Phone

Are you legally mandated to participate in a recovery program? ❏ yes ❏ no If yes, list by whom:

MC Workshops Residential

7291 Swamp St. NE Hartville, Ohio 44632 Phone: 330-244-6164

AUTHORIZATION FOR RELEASE OF INFORMATION

I, (Signature)

Date of Birth Social Security Number

Hereby grant permission to authorized representatives of MC Workshops Residential to: (Initial all that apply)

Release records about me from the agencies specified below: Initial

Exchange information about me with other agencies and prospective employers:

Initial

Initial

The Men’s Challenge

Initial P.O. Box 2002

Alliance, Ohio 44601 Phone: 330-823-6367

Other:

Initial

The purpose of this authorization is to allow MC Workshops Residential to discuss the program and its

participants with other potential participants and agencies and to allow us to stand as a reference for you to a prospective employer.

I consent to the release of the above information. I am aware that this information is Initial _{disclosed from records whose confidentiality is protected by federal law. Federal}

Regulations (42 CFR Part 2) prohibit either party from asking any further disclosures of information shared to any person/organization not specifically listed on this form without permission.

I do not consent to release/receipt/exchange of any information.

Initial

AUTHORIZATION FOR RELEASE OF INFORMATION (Continued)

This authorization will remain effective for 180 days unless an earlier date or condition/event is specified

here: Initials

1. I understand that I HAVE THE RIGHT TO REVOKE THIS AUTHORIZATION IN WRITING, by

sending/providing such written notification to the Case Manager at MC Workshops Residential, PO Box

446, Hartville, Ohio 44632. I also understand that a revocation is not effective to the extent that this Authorization has been relied upon for the use or disclosure of the protected information prior to a written request.

2. I understand that information used or disclosed pursuant to this Authorization may be subject to re-

disclosure by the recipient and may no longer be protected by federal or state law.

3. I understand that my housing will NOT be conditioned on whether I provide authorization for the

requested disclosure.

4. I understand that I have the right to refuse to sign this authorization.

5. I further understand that I have the right to inspect or copy the information to be used or disclosed as

permitted by law.

I hereby state that I have read, or have had read to me, and fully understand the above statements as they apply to me and do herein expressly consent to disclosure of the above stated information for the purpose or need stated. I understand and acknowledge that this Authorization extends to all or any part of the records designated above.

Signature of Individual Date

Witness Date

DOCUMENTATION OF GOALS

PLEASE LIST THE SPECIFIC GOALS TH AT THE CLIENT WILL WORK TOWARDS WHILE PARTICIPATIG IN THE MC Workshops Residential PROGRAM:

GOAL

I understand that regular meetings will be conducted on my behalf with my Case Manager.

Participant Signature Date

I agree to provide support to assist the participant with achieving their goals. I further agree to maintain

good contact with MC Workshops Residential staff a n d a t t e n d Case Management Meetings as necessary.