Client Application for WV Healing Center

Haven of Hope Healing & Training Center

Client Application

Name of person completing this form.*

Today's Date*

Name of Potential Client*

Client's Date of Birth*

Country*

Address (for Client)*

City, State and ZIP Code*

Phone Number (for Client)

Email (for Client)

Confirm Email (for Client)

Contact Person (for Client)*

Phone Number (for Contact Person)*

Email (for Contact Person)*

Confirm Email (for Contact Person)*

Contact Person's Connection to Client*

Cost:

$1,000 for the 1st week.
$750 for the 2nd week.
$500 per week thereafter (until discharge).

Additional $200 per Overcomers Course attended while doing the program.

We recommend a minimum 7 week program.

How long is the client wanting to stay? (We recommend 7 weeks)*

When would client want to arrive?*

Who is responsible for payment?*

What is the plan for payment?*

Is Client Currently Taking Any Medications?*

Yes
No
Don't Know

Is Client Currently Taking Nutritional Supplements?*

Yes
No
Don't Know

Describe reason for needing help...*

Other....

Terms and Agreements: (Check all boxes)*

1. I agree to respect and submit to the authority of the team.

.*

2. I agree to stay focused and follow instructions to the best of my ability.

.*

3. I agree to remain within the boundaries set by the team.

.*

4. I agree to surrender my car keys, cell phone, and all electronic devices to the authority of the team.

.*

5. On Sundays the team only does minimal mentoring according to the situation and/or circumstances.

.**

6. I understand that if client turns violent and destroys property at the Healing Center, client will be responsible for damages.

Confirmation

Name*

Email*

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