Online Application | Miracles Happen

Miracles Happen Recovery Residence 285 Stephens Circle Toccoa, Ga. 30577 Phone: (706)886-0307/ Fax (877)725-9152 Web:miracleshappenrr.org

Email: miracleshappenrr@windstream.net

All items on this application must be completed by applicant. Incomplete applications will not be considered for admittance.
Full Name
Phone Number
Please enter a valid phone number.
Street Address
City
State
Zip
Age
Birthday
Race
Do you have the following documents? Check all that apply

Birth CertificateState IDSS CardOther
Have You Been Here Before? If so When?
If yes, did you graduate from MHRR?
Do you owe us funds
Do you use tobacco products?

Cigarettes/CigarsVapesDipOther
Please be notified we are a tobacco-restricted campus. This means the use of tobbaco products are allowed in specific areas only. None indoors.
List Previous Recovery Facilities you have attended with dates and completion dates.
Emergency Contact Information
Emergency Contact Name
Relationship
Phone
Address
Applicant Relationship Information

SingleDatingLive InMarriedSeparatedDivorced
How long together
Number of children
Spouse/Significant Others Name
If divorced or separated, give date

MonthDayYear
Date
Applicant Parental Information (If living) If deceased please note in blanks.
Father's name
Telephone No.
Address
City
State
Zip
Mother's Name
Telephone No.
Address (if different)
City
State
Zip
Education & Skills
Highest Grade Completed

9th Grade10th Grade11th GradeHighschool DiplomaGEDCollege FreshmanCollege SophomoreCollege JuniorCollege SeniorTrade SchoolCollege Degree
Your skills and abilities (List all skills you have)
Last place of employment
Job Title
Date

MonthDayYear
Date
Job Description
Is your driver license valid
State where issued
Do you have any traffic tickets/DUI/DWI within the past 5 years?

YesNo
If so, where and when
Personal Medical History Completely
List all drugs/alcohol you have been or had been using and how long you have been using them.
Is there a history of substance use/abuse in your family?

Rate yourself in the following conditions.

	Excellent	Good	Fair	Poor
Physical
Mental
Emotional
Spiritual

Have you ever been verbally, sexually or physically abused by anyone?

YesNo
If Yes, Explain To Your comfort level.
Are you listed on the sex offender registry?

YesNo
Do you have any restrictions that will keep you from getting and performing a job?
If so, Explain.
Do you have any long-term medical issues we should be aware of (Heart disease, Epilepsy,Diabetes, HIV, Hepatitis A, B, or C, or TB) Please explain:
Please list ALL current medications you are taking, the reason, the dosage, and the prescribing doctor for each. Any medication that will give a positive on drug screens will disqualify you from MHRR program attendance.
Residents Primary Physician
Phone
Please list all other drug/alcohol facilities you have attended, the date, and did you complete the program.
Were you ever in the military?
Where?
Dates of Military service

MonthDayYear
Date
Rank
Gang affiliation
Rank
MHRR is a THOR/GARR-approved program so parolees may be accepted
Are you currently on Probation?Are you currently incarcerated?Are you currently under bond?Are you currently on Parole?
Please list all convictions and dates of incarceration of any type within last 5 years.
Are you mandated to be here or in another program?

YesNo
Upcoming Legal Issues
Supervising Officers Name
City
State
Zip
Telephone
Fax
Are you scheduled to be in court or attend any hearings within the next 12 Months? If so, please list.
Financial Responsibilities are currently at $900.00 entry fee and $200.00 weekly. Charges may change without notice, so call for verification. If accepted, you will be required to sign a 12- month (52) week contract for which you will be held responsible even if you decide to leaveour program before completion. It is your responsibility to meet these due fees and you may be dismissed if they are not met. Entry fee is due either before or on day of arrival to facility and is NON-REFUNDABLE. Initial for financial acknowledgement and agreement.

PROGRAM AGREEMENT

Please indicate by your signature that you have read the following statements, understand the statements, and agree to abide by them. If you do not sign this form or disagree with this form, we cannot accept you into our program. Initial each of following statements.
1. I will be tested as soon as possible for TB, Covid 19 and will have the results forwarded to MHRR. I understand that a reactive or positive result from lab work MAY disqualify or postpone me from admission. I agree to get fully vaccinated for Covid 19 all future variants within 30 days of arrival. I agree to begin this process within 48 of intake.
2. I understand my application will not be reviewed by the application committee nor I be put on waiting list until MHRR has received my completed application and criminal history.
3. I understand I must be 21 years of age or older to be accepted into the program.
4. I understand that if I am approved and scheduled for an intake date, I will be on time and prepared to stay.
5. My signature indicates that I am coming of my own free will. I hereby agree to cooperate with staff and abide by all rules. I also agree to submit to random screening which may be in the form of urine, breath, or salvia. I agree to pay current cost of any failed screens at time of testing.
6. I do assume risks that might be incidental to my stay; and I do hereby for heirs, executors, and my administrators, myself, or any representatives, release and relinquish forever, any and all claims of any nature whatsoever that may arise out of or in connection with my stay here.
7. If after acceptance into MHRR we find that any of the information is either untrue has been omitted, it may be grounds for dismissal and there will be NO REFUND of any funds paid.
By signing this form, I agree to all the terms above.
Signed

Clear
Date

MonthDayYear
Date
Personal Letter Write a letter to MHRR Staff as to why you wish to come to MHRR. This is your chance to sell yourself to the committee.
Should be Empty:

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