Application Logo
  •                                   Shalom Recovery Center Applcation

    "For I know the plans I have for you, declares the Lord. Plans for welfare and not for calamity to give you a future and a hope."

    Jeremiah 29:11

  • Shalom Recovery Center requires a VD and a pregnancy test before being accepted. These can be obtained at the health department. 

    Shalom Recovery Center offers 12 week, 24 week, 36 week sessions. Our fee is $2,700 for each 12 week session. The fee is nonrefundable. Applicants must be interviewed prior to consideration and acceptance.

  • General Information

  •  - -
  •  - -
  • Emergency Contact Information

  • Drug Use

  • Please list the dates you last used the following drugs:

  • Legal Issues

  •  - -
  • Medical History

  • Honest answers to these questions will not disqualify you from the program.

  • Religious History


  • My signature indicates that I am applying for residence at Shalom Recovery Center of Shalom House Ministries on my own free will. I agree to cooperate in the work program and obey all the rules. I assume any and all risks incidental to my residence at Shalom Recovery Center. Applicant shall be responsible to insure Applicant's personal property against loss or damage. Applicant releases Shalom House Ministries from liability for and agrees to indemnify Shalom House Ministries against all losses incurred by Shalom House Ministries, including, but not limited to, attorney's fees, as a result of: (a) Applicant's failure to fulfill any condition of this Lease; (b) any damage or injury happening in or about the Property to Applicants or Applicant's invitee or licensees or such persons' property, except where such damage or injury is due to gross negligence or willful misconduct of Shalom House Ministries; (c) Applicant's failure to comply with any requirements imposed by any governmen authority; and (d) any judgment, lien or other encumbrance filed against the Property as a result of Applicant's actions. On behalf of my heirs, executors, administrators, myself, and any representative, I hereby release forever any and all claims arising out of or in connection with my residence at Shalom Recovery Center. I also give Shalom House Ministries, Inc. permission to release information and records as required by law.

  •  - -
  • Should be Empty: