Ending Addiction & Modeling Christ
804-451-4481 info@regenesislife.org
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Hannah’s Home Application

Hannah’s Home is a transformative twelve-month biblical-based Christian residential program designed to support mothers who are grappling with addiction or other life-controlling issues. Hannah’s Home provides a safe, loving, and structured environment for  both mother and child, eliminating the need for separation during this critical period.

Application Fee Policy

A non-refundable application fee of $100 must be paid in full before your application will be fully processed. Once your application is submitted, the Regenesis staff will review it and reach out to schedule an initial interview. If the staff determines that you are eligible to continue in the application process, after that, then the $100 application fee will then be required. This fee must be paid before your application can proceed to the final stage, where a decision will be made regarding acceptance or denial. Pay here or after submitting the application below. 

Hannah's Home Application

PERSONAL DATA AND INFORMATION

Sexual Orientation:
Address
Address
City
State/Province
Zip/Postal
Do you have a valid driver's license?
Do you have a Physical proof of license?
If no, do you have a valid ID?

NEXT OF KIN/IN CASE OF EMERGENCY

First Person
Address
Address
City
State/Province
Zip/Postal
 
Second Person
Address
Address
City
State/Province
Zip/Postal

WHO HAS REFERRED YOU TO REGENESIS?

Address
Address
City
State/Province
Zip/Postal

MEDICAL HISTORY

How would you describe your current state of health?
Are you presently receiving medical care?
Are you on any medication, including psychiatric?
Do you have any special diet requirements?
Do you have any allergies, including food allergies?
Do you wear prescription glasses?
Are you experiencing problems with your teeth?
Have you ever received mental health treatment?

INSURANCE INFORMATION

Have you ever experienced or presently have a physical ailment, injury, or handicap that would prevent you from performing manual, work-related tasks while enrolled at Regenesis?
Have you had or have any of the following?      If yes, list the Date of Treatment
Hepatitis
Epilepsy/Seizures
Allergies
Tuberculosis
Diabetes
Ulcer
Abscess
Venereal Disease
Asthma
Arthritis
High Blood Pressure
Back Problems
Surgery
Broken Bones
Dietary Issues/Restrictions
Sexually Transmitted Disease
Is it easy for you to express your feelings?
Do you enjoy being around people?
Do you smoke or use tobacco in any form?
Regenesis has a no-smoking or tobacco use policy. Are you willing to abide by this policy?
Are you pregnant?
Are you under a doctor’s care for this pregnancy?
Have you used drugs, alcohol, or nicotine during this pregnancy?
Are there any health problems with this pregnancy?
Do you intend to keep your baby?
Have you had an abortion?
Have you been sexually abused?
Have you ever been involved in prostitution?
Do you have regular menstrual cycles?
Do you bleed between periods?
Have you experienced menopause?
Have you ever experienced an eating disorder (anorexia, bulimia, etc.)?
As a student of our program, would you be willing to authorize doctors or agencies involved in previous treatments to release the above-mentioned confidential information to Regenesis?

MARITAL/INTIMATE RELATIONSHIP HISTORY

Marital Status:
Address
Address
City
State/Province
Zip/Postal
Do you have any other children?

Child Info

Add Another Remove

PARENTS INFORMATION

Parent's Status:

SIBLINGS

List the names and ages of any brothers and sisters.
Add Another Remove

SIGNIFICANT LIFE EVENTS

Describe any of the following that you are experiencing or have recently experienced.

WORK AND EDUCATION HISTORY

Last year of education completed:
College:
Can you write?
Can you read?

PSYCHOLOGICAL HISTORY