New Life Recovery Program

A ministry of the Redwood Gospel Mission

101 6th Street, Santa Rosa, CA. 95401 
Phone: 707-542-4817 Fax: 707-544-6185

NEW LIFE RECOVERY PROGRAM APPLICATION FOR ADMISSION

This is a huge step forward in your recovery. It takes a tremendous amount of courage to even apply to a program. We hope to be an encouragement to you as you move forward. We are not here to judge you; we are here to help. Please know that your information will be treated with the utmost respect for privacy. Any information obtained is for the sole purpose of determining if this program is a good fit for your needs and will not be released to any outside agency for any reason without your specific written consent to such a disclosure.

There are a few things we would like to tell you about our program up front:


1. We are faith-based. You do not need to be a Christian to enter and we do not require

that you become a Christian at any point in the program. However, our program is Bible-based and we do lead our classes from a Christian perspective. All we ask of you is for an open-minded and willing attitude towards Christian teachings.

2. Our program is not able to accommodate anyone using narcotics, benzodiazepines, or muscle relaxers. Other medications such as, but not limited to, psychotropics, anti- depressants, and ant-anxiety medications will be addressed on a case by case basis, but are not necessarily disqualifiers.

3. We are a non-smoking program. Nicotine is a highly addictive drug and we recognize its negative impact on your overall health and well-being. You may use nicotine replacement therapies during the first 30 days of the program, but must be nicotine- free before phasing into the program.

4. We are a time-out from romantic relationships (except for a legal marriage)


5. Because our program is designed for those who have no other resources, those

accepted into the program are not allowed to accept any outside income (such as SSI, SSDI, Unemployment, GA, etc.) while in the program. We ask that if you are unwilling to discontinue the outside income, that you assign a payee that will work together with program management to safeguard your savings.

6. The program can accommodate up to 40 men. Space is limited and so we do have guidelines on the number of items you can bring into the program. More information on this will be provided upon your acceptance.

Please fill out your application clearly and honestly. If possible, please follow up by phone after submission. Contact Bryan Bush (NLP Mgr.) at 707-542-4817 or by email
at bbush@srmission.org. You may also contact him with any questions you may have on the information stated above. May God guide and protect you on your quest for a New Life!!

Life Controlling Issues

Have you ever participated in a 12-step program?
Did you complete all 12 steps?
Did you complete all 12 steps with a sponsor?
Do you use tobacco of any kind? (Includes e-cig or vaping)
Are you willing to quit?

Legal Status

Do you have an attorney/public defender?
Are you on probation?
Do you have to register with the police department?
Do you have any court ordered classes (ex. DDP/Anger Management)?
Are you currently incarcerated?
Is it contingent upon acceptance into a program?

Financial Information

Do you receive a monthly income? (ex: SSI or Unemployment)
Are you expecting any outside source of income?
Are you willing to designate a payee for any income that you receive after entering the program?

Family Information

Marital Status: (circle one)
Do you have any children?
Do you have friends/relatives who work for the RGM?

Spiritual History

Are you open to the possibility of God’s Spirit transforming your life based on Biblical principles?

Health History

Please describe your health:
Have you ever been diagnosed with a mental health condition?
Have you been prescribed medication for your condition?
Are you currently taking this medication or any other medications?
Are you able to lift 25 lbs.?
Are you able to use the stairs?

Other Information

Are you a veteran?
I agree to give up any unmarried romantic relationships and refrain from new ones while in the NLP:

Thanks for submitting!