LOYAL TO ONE MINISTRIES

4708 Fenton, Garden City 83714

HOUSE INTAKE FORM Name: __________________________________________________________________ Last First Middle Date of Birth: _______________Place of Birth:_______________ID:________________ Hair color:___________Eye color____________Phone#__________________________ Ht.__________Wt._________ Race__________ Are you a Veteran? Yes No Spouses name and location________________________________________________ _________________________________________________ Childrens names and ages:_________________________________________________ ________________________________________________________________________ What are your plans for locating permanent housing?_____________________________ ________________________________________________________________________ Are you employed? Yes No If so, what are your days and hours?___________________________________________ Do you have any source of income? Yes No If so what is that source and how much?_______________________________________ Are you taking prescription drugs? Yes No If so, please name them_________________ ________________________________________________________________________ Have you used alcohol or drugs in the past? Yes No Are you addicted? Yes No Do you need help with any dependence problems? Yes No Are you a registered sex offender? Yes No Are you on probation or parole? Yes No Name of probation officer_________________ Are you aware if any outstanding warrants for your arrest? Yes No If so what jurisdiction?_____________________________________ -----------------------------------------------------------------------------------------------------------I affirm that the above information is true and complete to the best of my knowledge. I understand that if any of the above information is materially false, I may be expelled from the facility. ____________________________________________ _______________________ Signature Date Admission date________________Discharge date_______________Intake by ________

LOYAL TO ONE MINISTRIES

4708 Fenton, Garden City, 83714

RULES OF CONDUCT If you violate any of the following rules, you will be asked to leave and may be prohibited from returning You must respect and obey all instructions given by any staff. Threats or acts of violence will not be tolerated. If you make threats or act in violence, or destroy someone elses property, you will be asked to leave. Illegal drugs or alcohol, of any kind is absolutely prohibited on or near the property. Anyone on property with illegal drugs or alcohol, or found under the influence will be asked to leave immediately. Conduct unbecoming of a guest will not be tolerated at or near the ministry facility. Unbecoming conduct includes, but is not limited to: - Any illegal activities. - Cursing or use of foul language. - Actions or behaviors which are harassing, disruptive, rude or confrontational. - Any sexual activities and possession of pornographic or sexual materials or clothing INFORMAL RULES The following rules govern your stay at the ministry house. If on parole you will show your aftercare requirements and strictly adhere to them. Smoking will be allowed in designated areas only. Food is not allowed in rooms. Kitchen will be cleaned directly after meals have been prepared. Curfew is 10:00 pm. Any one out past curfew must have prior approval. Daily showers are mandatory, unless proof of documented medical condition All men will be assigned a daily task or chore. If these are not completed, the next day there will be a double chore. And if not completed on that day there will be disciplinary action taken. You will attend morning devotional every morning except Sunday when you are required to attend church services. You must be respectful with electronic devices, volumes at acceptable levels, after 9:00pm headphones must be used. All persons bags and belongings are subject to search at any time with or without prior notice. You will be up and rooms will be cleaned by 8:00am, beds made etc. windows during summer time when air conditioner is on will be kept closed. Prescription meds. will be locked up and distributed as prescribed by manager By my signature I acknowledge that I have read and understand all the above rules. Signature Date

LOYAL TO ONE MINISTRY OUR GOAL FOR YOU 1. We here at Loyal To One Ministry want to help with your reentry back into society. 2. We are an Evangelical Christian Ministry and will focus on a healthy, balanced God centered lifestyle and we will provide all that we can for you to achieve this. 3. You may or may not be charged rent depending on individual basis and circumstances. 4. We will assist with transportation to S.S.I. P & P, Classes, Medical appointments, Health & Welfare and other support services you may need go to upon your release. 5. We offer this however on a 30, 60, 90 day basis and expect to see a valid life plan before we accept you. 6. We are not here to give you a hand out but instead a hand up. We believe the only way to have a successful reentry and future is total commitment to God in all areas of your life. We have walked in your shoes and know the path to success and we are committed to helping you do the same. Just remember each of us has an active part in this relationship, God will do His, we will do ours and youll have to do yours. 7. We hope to build a network of successful Christian men who will stay in touch with us as they move on with their lives. We want you to come back and share what God has done in your life and if unable to find a home church be a part of the Loyal To One Ministry body. 8. No man is ever more than four steps from God. Conviction, Repentance, Consecration, & Faith. Being divinely empowered so that one grows stronger in Christ has nothing to do with performing spectacularly or even successfully (whether or not we perform is up to God). Heres what matters Personal holiness before God Personal communing with God Personal service of God Personal action for God

9. We look forward for in serving you in Gods love and grace.

God Bless, Ministry Team of L.T.O.M.

LOYAL TO ONE MINISTRY

4708 Fenton, Garden City, 83714

RELEASE OF LIABILITY
This Release of Liability (this Release) executed by the undersigned (Guest) in favor of Loyal To One Ministry a privately run transitional facility and its directors, officers, employees, volunteers, landlords and agents (collectively, L.T.O.M.) Guest desires to receive certain services. Assistance of benefits from L.T.O.M. directly or indirectly, which may include, but may not limited to, food, shelter, clothing, counseling, education, medical care, employment, assistance, services and other matters (collectively, Services). L.T.O.M. will not provide Services Guest without this Release, and therefore Guest does hereby freely and voluntarily execute this Release to receive such Services. Release. Guest hereby waives. Releases and discharges L.T.O.M. from any and all liability.., claims and demands of any kind or nature whatsoever, either in law or in equity. That may arise from or be related to the Services or Guests presence at L.T.O.M. facility, including, claim. Demand or damage that Guest may now have in the future with respect to any bodily injury. Personal injury, illness, death, property loss or property damage, even if caused in whole or in part by the negligence of L.T.O.M. Consent to Medical Treatment. Guest hereby authorizes L.T.O.M. to provide any medical treatment or other care that L.T.O.M. deems appropriate in any circumstance where, in L.T.O.M. judgment, Guest does not have, or does not readily appear to have, the ability to make reasonable medical treatment and care decisions for himself. Guest hereby waives and releases L.T.O.M. from any claim whatsoever that may arise from or may be related to L.T.O.M. provision of any medical treatment or other care to Guest. Guest understands that L.T.O.M. does not provide medical insurance for Guest and that Guest will be responsible for the cost of any medical care that Guest receives. Assumption of Risk. Guest understands that there will be other persons at L.T.O.M. facility from time to time, and that Guest may be in proximity or contact with such other persons while at L.T.O.M. facility. Guest acknowledges that such other persons present risks of potential bodily injury, personal injury, illness, death and property loss or property damage, by way of example, and without limitation, such other persons may have contagious diseases, may have mental illness, maybe reckless, may be dishonest, may steal, may have weapons, may have drugs, may have violent tendencies or a history of violence toward himself or others, may be careless or hurtful or defamatory statements. Guest understands the Guest will take precautions to protect himself from the foregoing risks, Guest waives and releases L.T.O.M. from any and all liability, claims and demands of any kind or nature whatsoever, either in law or in equity, that may arise from or be related to foregoing risks, even if such risks were in whole or in part by the negligence of L.T.O.M. Work/Task Assignments. Guest understands that he may be asked to do work or tasks for L.T.O.M. Guest assumes the risk of injury or harm in any such activities and hereby waives and releases L.T.O.M. from any liability or claim for bodily injury. Illness, death or property damage resulting from such activities. Photographic Release. Guest hereby grants L.T.O.M. the right to take and use photographic images, video recordings and audio recordings of Guest as L.T.O.M. desires. Guest hereby disclaims any right to such images and recordings. Including, but not limited to, any royalties, proceeds or other benefits derived from such photographs or recordings. This Release is intended to be as broad and inclusive as [permitted by law. If any clause or provision of this Release is held to be invalid by any court of competent jurisdiction, the invalidity of such clause or provision shall not affect the remaining provisions of this Release which shall continue to be fully enforceable. IN WITNEES WHEREOF, Guest has executed this release as of the day and year set forth below. Witness:___________________________________Guest____________________________________________ Signature ____________________________________________ Printed name ____________________________________________ Date

LOYAL TO ONE MINISTRY

4708 Fenton, Garden City, 83714

(208) 286-6489

The following is a list of programs offered at the transitional house: 1. Safe People. This class is required the first 2 weeks out. This is a relationship boundary class developed by Henry Cloud and John Townsend. 2. Faith Based AA Meetings. 3. One hour each day spiritual mentoring with Pastor Evaneski. 4. Transportation to and from CSC 2 Intensive Outpatient treatment program either with other housemates at District 4 P&P or through a private provider as may be required. 5. Drug and Alcohol classes at the facility to support the 90 in 90 day meeting requirement. 6. Support Group meetings as desired. 7. Random UA testing 8. Anger Management Classes

LOYAL TO ONE MINISTRY

4708 Fenton, Garden City, 83714

(208) 286-6489

MY GOAL

WHERE AM I NOW? PHYSICALLY_________________________________________________________________ ______________________________________________________________________________ SPIRITUALLY_________________________________________________________________ ______________________________________________________________________________ MENTALLY___________________________________________________________________ ______________________________________________________________________________ CAREER/JOB_________________________________________________________________ FAMILY______________________________________________________________________

WHERE DO I WANT TO BE IN___________________________(YRS/MONTHS)? PHYSICALLY_________________________________________________________________ ______________________________________________________________________________ SPIRITUALLY_________________________________________________________________ ______________________________________________________________________________ MENTALLY___________________________________________________________________ ______________________________________________________________________________ CAREER/JOB_________________________________________________________________ FAMILY______________________________________________________________________

LOYAL TO ONE MINISTRY

4708 Fenton, Garden City, 83714

(208) 286-6489 REDISCOVERING YOUR INNER SELF WHO AM I? ______________________________________________________________________________ ______________________________________________________________________________ WHO DO I WANT TO BE? ______________________________________________________________________________ ______________________________________________________________________________ WHAT ARE MY GOALS? ______________________________________________________________________________ ______________________________________________________________________________ WHEN DO I WANT TO REACH THESE GOALS? _____________________________________________________________________________ ______________________________________________________________________________ WHAT IS IMPORTANT IN MY LIFE? ______________________________________________________________________________ ______________________________________________________________________________ WHAT ARE MY VALUES? ______________________________________________________________________________ ______________________________________________________________________________ DO I BELIEVE IN MYSELF? ______________________________________________________________________________ DO I DESERVE TO LIVE A GOOD LIFE? ______________________________________________________________________________ WHO CAN HELP ME REACH MY GOALS? ______________________________________________________________________________ WHO CAN GET IN MY WAY OF MY GOALS? ______________________________________________________________________________ NOTES: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________