Client Application for Haven of HopeTraining Center

Client Application

Name of person completing this form.*

After you submit your application, we will plan to call the contact person within a week or so.

Today's Date*

Name of Potential Client*

Client's Date of Birth*

Address (for Client)*

Phone Number (for Client)

Yes, it's okay to send me text messages including confirmations, changes, and updates. Message frequency varies. Message and data rates may apply. Reply STOP to cancel. View our terms of service & privacy policy.

Email (for Client)

Confirm Email (for Client)

Contact Person (for Client)*

Phone Number (for Contact Person)*

Yes, it's okay to send me text messages including confirmations, changes, and updates. Message frequency varies. Message and data rates may apply. Reply STOP to cancel. View our terms of service & privacy policy.

Email (for Contact Person)*

Confirm Email (for Contact Person)*

Contact Person's Connection to Client*

How did you hear about us?*

Cost:

$100 per day

We recommend a minimum 14 week program.

How long is the client wanting to stay? (We recommend a full term which is 14-17 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 Haven of Hope..

.*

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

.*

5. On Saturdays & 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 Training Center, client will be responsible for damages.

Confirmation

Email*

Name*

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