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Dear Applicant,

If you are considering applying to Merci's Refuge then you should have already read about our program goals, overview, and requirements. If you have not received that information or spoken with a representative from Merci's Refuge please call 217-378-4045 to request more information first. 

Once you are sure Merci's Refuge is a program you would like to be considered for, and you truly desire help in a residential Christian atmosphere, and are willing to adhere to the program requirements, then please continue our assessment process by completing the included application. 

We hope the information you share will help us begin to know you and understand your current situation, and what you hope to accomplish while at Merci's Refuge.  It will also help us determine if Merci's Refuge is an appropriate program to meet your specific goals and provide for your needs.  If you have any questions or concerns while completing the application please contact us right away.


Please follow the following steps to complete your application:

  1. Read the enclosed information titled Understanding the 30 Day and 6 Month Commitment Agreement, Program Overview, and Resident Handbook. You will be asked to sign contracts regarding these documents upon acceptance into the program.
  2. Complete the Merci's Refuge Application. The entire application must be completed by the applicant. We will not be able to consider or process incomplete applications.
  3. Make a doctor's appointment or visit your local health clinic to have a general physical completed and obtain immunization records.
  4. Obtain all medical reports, psychological reports from the past 2 years and current immunization records. Please be sure to obtain all necessary items presented in the summary checklist below.
  5. Send us your completed information.  This includes the Merci's Refuge Application and all medical information from the checklist.  This information should be sent to Merci's Refuge, PO Box 1563, Champaign, IL 61824.
  6. Contact Merci's Refuge staff to confirm your application forms have been received.  If you mail your application, please allow four days for delivery before calling, 217-378-4045.
  7. Once we receive and review your application, you will receive a phone call to schedule a telephone interview with a staff member. Interviews generally last 60 minutes and are scheduled in advance. Once the interview is completed, your application will be presented to our Intake Committee.
  8. The Intake Committee will determine each applicant's acceptance or denial into the program. If accepted, a date of admission will be set. If no space is available, you will be placed on a waiting list and given further instructions. If denied, appropriate referrals will be given whenever possible.



  • Read the description of the Commitment Agreement titled Understanding the 30 Day and 6 Month Commitment Agreement.
  • Fill out your personal responses on the Merci's Refuge Application.
  • Schedule a doctor's appointment for a general physical.


  • Physician's statement that you are physically and emotionally stable and appropriate to be admitted to a non-medical residential program
  • Current immunization records
  • Release(s) of Information
  • Treatment summaries from mental health &/or substance abuse programs (past 2 years)
  • Upon completion of the previous steps, send all information to Merci's Refuge:
    Address: Merci's Refuge, PO Box 1563, Champaign, IL 61824.
    Fax: 217 378-4051 Email:
  • Call (217) 378-4045 to confirm that your application materials have been received.

Please know that your cooperation in completing all the above steps is the quickest way to enter the program. We understand many women want and need help quickly; however, we abide by these guidelines to ensure that everyone is treated fairly.

I will be happy to answer any questions you may have so feel free to contact me!

In His Love & Service,

Greta Henry
Merci's Refuge
(217) 378-4045


This information is confidential. The information in this application will not be held against you or used to judge you in any way. Merci's Refuge is committed to helping women in need of hope and healing. If for any reason we cannot meet your particular needs, we may be able to refer you to someone who can. Please answer all questions honestly so we may know how to best help you. Answer all questions and do not leave spaces blank as this will delay your application. If a question does not apply to you, please write NONE or N/A next to it.



Basic Information

Present Address

Information about You

Education and Employment




Merci's Refuge provides food, shelter and counseling/support services. We are not responsible for medical expenses or prescriptions. It is the responsibility of the resident and/or her sponsor(s) to cover these expenses. Arrangements must be made in advance of residency. If none of the below sources of support are available to you please inform the Program Coordinator during your intake interview.


Substance Use

Counseling History

Spiritual/Religious Beliefs


Often the negative thoughts, emotions and behaviors that people desire to change are rooted in past traumatic and hurtful experiences. Many of our staff have experienced abuse in one form of another at some point in their life. We know it can be extremely difficult to walk through, acknowledge or discuss. Merci's Refuge is an intensive program designed to bring healing to deep emotional wounds so it is important for us to know that our residents are ready to acknowledge their pain and are willing pursue healing and freedom.

By submitting the application I understand that if I have not answered these questions honestly or withheld any information, it can be considered grounds for refusal in to or dismissal from the program.

(*) Denotes required fields


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