Online Application

New Beginnings Home for Men (NB) and Marjorie Oakley Home for Women (MOH) are faith-based, Level III Substance Use Recovery Residences operated by Recovery Group of Southern West Virginia, Inc. (RGSWV). Each residence offers up to 18 months of recovery support, structured in three phases that residents must complete to graduate. We only accept residents who are not taking Suboxone, Subutex, Sublocade, or Methadone, except for those who have received a single dose of Sublocade or Brixadi (no ongoing shots or MAT will be provided; you must be able to remain abstinent without further MAT). Vivitrol is the only MAT we support for ongoing use. We do not accept applicants with violent felonies or sex offenses.

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Thank you for your response. ✨

Name (First, Middle, Last)

Race/Ethnicity

Gender(required)

Male

Female

Mailing Address

City, State, Zip

County

Email Address

Location of Current Residence (give details)

Phone Number

If Other, explain

Supervisor (i.e. Probation/Home Confinement Officer, Counselor, Attorney, etc.)

Counselor/Attorney

Sentencing Judge

Emergency Contact (Full Name)

Phone Number (___-__-____)

Relation

Mailing Address

City, State, Zip

Driver License/ID Information (Type, ID#)

Social Security Number (___-__-____)

Date of Birth (YYYY-MM-DD)

Do you have a current felony conviction for which you are being referred? (This must be your CURRENT charge)(required)

Yes

If Yes, Explain

List previous legal charges of which you have been convicted

List and describe any and all past convictions that are violent in nature:

What is your Primary drug of choice? Second? Third?

Describe history of use (first use, last use, amount/frequency, route of administration)

Describe your longest amount of sobriety (incarcerated vs unsupervised, age, length of time, medically assisted)

List and describe prior substance abuse treatment

Personal sobriety date (YYYY-MM-DD)

Are you currently experiencing any symptoms of withdrawal?(required)

Yes

Please list and describe any significant medical issues at this time

Please list any current medications

Please list any medications that you have used /have had prescribed in the past 30 days

Have you ever been diagnosed with a mental health diagnosis?(required)

Yes

If yes, describe past and present symptoms pertaining to each reported diagnosis

If you have ever received mental health treatment, please list and describe. (where, diagnosis, when, duration, prescriptions provided)

If you have ever experienced thoughts, plans, or taken action to hurt yourself or someone else, please explain.

Please explain your motivation for treatment at this time

What help do you believe you need at this point in your recovery?

Why are you interested in receiving treatment from Recovery Group of Southern WV and/or Directions of Southern Regional Day Report Center?

Are you committed to participating in a residential treatment program for 8 to 12 months?(required)

Yes

Explain

Do you have a sponsor, home group, or a connection to a greater recovery community?

Please describe any form of support (mental, emotional, financial, spiritual) that you will have at this time and any support you believe you will have after completing the program

Do you agree to participate in a Christian based community?(required)

Yes

List Prior Occupations

Do you have a source of income? (i.e. Pension, Retirement, Disability, SSI, etc.)(required)

Yes

Details

Are you a Veteran?(required)

Yes

Details

Thank you for your response. ✨

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