Ending Addiction & Modeling Christ
804-451-4481 info@regenesislife.org
APPLY NOW

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

Have you ever received mental health treatment?

Mental Health Treatments

Add Another Remove
Have you ever thought about committing suicide?
Are you currently thinking about committing suicide?
Have you ever attempted suicide?
Has a family member or someone close to you attempted or committed suicide?
Have you ever received psychiatric care?
Have you ever cut yourself?
Are you currently cutting yourself?
If you have received treatment for self–harm, please list:
If more than once, please list all treatments.
Have you ever had an eating disorder?
If you have received treatment for an eating disorder, please list:
If more than once, please list all treatments.
Will you be willing to authorize doctors or agencies involved in previous treatments to release your medical records?

SPIRITUAL HISTORY

Are you born again?
Are you a member of any church?
Have you, your parent, or grandparents ever been involved in any occult, cultic, new age, or any other non-Christian practices?

LEGAL HISTORY

Are you legally mandated to participate in a residential program?
If yes, by whom?
Are you currently or will you be under legal supervision?
Method of reporting:
Address
Address
City
State/Province
Zip/Postal
Are any of the following pending against you? (Please check those that apply)

List all arrests and major convictions other than traffic violations:

Conviction?
Were Alcohol or Drugs Involved?
Add another Remove

Attorney's Information

Please List the Dates and charges the above Attorney is representing you on:
Add another Remove

FINANCIAL STATUS

Are you eligible for and/or receiving the following:
Are you receiving food stamps?
Do you have a food stamp card?
Are you receiving Childcare assistance through social services?
Do you have any outstanding debts, including child support?
Have you ever made a payment?
Do you have the means to cover the payments while you are in the program?
If yes, please give details:
Do you have the means to pay the program fees if approved for Hannah’s home?
Does Regenesis have permission to contact this person to arrange program fee arrangements?

THE PROBLEM

Have you ever been in treatment before:
Where did you receive treatment? (Please list the most current place you received treatment)
Did you successfully complete the treatment:
Have you received treatment more than one time?
If yes, you will be asked to explain during your initial phone interview. Please be prepared to share this information in detail.

Drug

If you did not use the drug listed, leave it blank.

First Time

How old were you or what month/year?

Last Time

Please list the approximate date of last use.

Frequency

How often did you use it: occasionally, monthly, weekly, daily, etc?

Amount Used

How much did you use per day/week/month?

Final Questions

Have you ever been in a Regenesis program?

Alternate and Signature

*If the enclosed application form has been completed or filled out by any other individual, please provide the following:
A non-refundable application fee of $100.00 must be received with your thoroughly completed application, or your application will not be processed. (Money orders payable to Regenesis)
Once our intake staff has received your completed application and application fee, you will be contacted to set up an initial phone interview.

Incomplete applications may not be processed.