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But a certain Samaritan, as he journeyed, came where he was: and when he saw him, he had compassion on  him.
And went to him, and bound up his wounds, pouring in oil and wine, and set him on his own beast, and brought him to an inn, and took care of him.

Luke 10:33 & 34

If you look at them through the eyes of Christ, you can see past the harshness and anger in their faces...

Pastor Remington

Some Statistics...
90% of all meth users become addicted on their first use.

According to a 1997 report, 4.4% of American teenagers have tried meth (and that number has increased at least 30% since then).



 



Confidential Application



This is a confidential application. Please print out this form, fill in all applicable information below and fax it to Good Samaritan Rehabilitation; 208-667-4078.  If your application is approved, a copy of this will be signed in the presence of the director of Good Samaritan Rehabilitation, or an authorized delegate of the director and will be kept on file by Good Samaritan Rehabilitation.


* INDICATES REQUIRED INFORMATION. For required fields that you do not have the information, enter NA


*Date  

*Name  *Phone  

*Spouse     *Phone  

Emergency Contact:
*Name   *Phone  

Children

Name

Age

 

 

*Are you pregnant? Yes No

*If yes, what is the due date?  

*Nearest relative: Name   *Relationship  

*Have you ever been through an intensive in-house treatment? Yes No

*If yes, where?   *Dates: From   To 

*What drugs did you use? (list all)

*How long have you used drugs?  

*Have you ever been molested? Yes No

*If yes, was it with a family member? Yes No

*Are you in trouble with the law? Yes No

*I yes, explain thoroughly

*Probation officer   *Judge  

*Prosecutor  

*List all court dates  
 
 

*Are you on any medications? Yes No

*If yes, list all and reason for use:
  

*Do you have a job? Yes No

*If yes, where?  

*Do you have a valid drivers License? Yes No

*Do you have a motor vehicle? Yes No

*How did you hear about this program?

*Are there any reasons you could not physically work in the home? Yes No

*If yes, explain thoroughly

*Can you financially afford the 30 day treatment of $1,500? Yes No

*If yes, explain how

*Have you ever been diagnosed with anything? (sexually, mentally, physically, socially) Yes No

*If yes, explain thoroughly

*Have you ever been violent? Yes No

*If yes, explain

This is a 30 day program. All contracts will be terminated after 30 days unless otherwise approved by the Director.  All visitors, phone privileges, trips, meetings and letters must be approved by the director.  This is only an application. It will be reviewed by the Director or an authorized representative and you will be contacted by phone.  Thank you.


Pastor Tim Remington


Justine Fellows

But whoso hath this world's good, and seeth his brother have need, and shutteth up his bowels of compassion from him, how dwelleth the love of God in him? My little children, let us not love in word, neither in tongue; but in deed and in truth.
I John 3:17 & 18

"If you want to raise a man from mud and filth, do not think it is enough to keep standing on top and reaching down to him a helping hand. You must go all the way down yourself, and then take hold of him with strong hands and pull him and yourself out into the light."
Jewish Proverb

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