Apply now

Dear Applicant,

If you are considering applying to Merci's Refuge then you should have already read about our Program Overview and Resident Handbook.  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 confident Merci's Refuge is the right program for you at this time then please continue our assessment process by completing the online application at the bottom of this page, or request a paper application. 

The information you share with us will remain confidential and will help us begin to get to know you and understand your current situation and what you hope to accomplish in your life while at Merci's Refuge and beyond.  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.



  1. Read the Program Overview, and Resident HandbookYou will be asked to sign contracts regarding these documents upon acceptance into the program.
  2. Complete the Merci's Refuge Application online or request a paper copy. The entire application must be completed by the applicant.
  3. Obtain and submit treatment summaries from all mental health and/or substance abuse programs from the past 2 years and current immunization records. Please be sure to obtain all necessary items presented in the summary checklist below.
  4. 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.
  5. Once we receive and review your application, you will receive a phone call to schedule a telephone on in-person 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.
  6. 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.



  • 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.





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, basic toiletries, 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.


Addiction History


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


© 2018 - 2020 Merci's Refuge - All Rights Reserved.