General
Tell us about yourself
What is your first name?
Client first name
What is your middle name? No middle name? Move on to the next question.
Client middle name
What is your last name?
Client last name
When is your birthdate?
Client birthdate
What is your race/ethnicity?
Client race
What is your Social Security Number
SSN
What is your gender?
Client gender
What is your marital status?
Client marital status
Does your spouse support your desire for recovery?
Text field
Do you have any children? If so, how many?
Text field
Are you a veteran?
Client veteran status
Are you out on bond, probation, or parole? If yes, please list the officer's contact information.
Medical History
Tell us about your medical history.
Have you been clinically diagnosed with any mental health disorders? Add multiple by clicking in the box and selecting different options
Client diagnosis
Do you have any health problems? Add multiple by clicking in the box and selecting different options
Client health problems
What allergies do you have? No allergies? Move on to the next question.
Client allergies
Do you have any disabilities that will prevent you from using a bunk bed?
Dropdown
Have you had any of the following tests?
Medical Tests
Recovery Commitment
What date are you looking to admit into the recovery program?
Date
Are you willing to make a 6-month commitment to this program?
Dropdown
Do you agree to random drug tests?
Signature
If you have been in recovery before, what makes this time different?
Paragraph
Here at 143 Ministries, we believe in relationships. To get to know you better, we ask that once you have completed this application, please call 1-800-560-7143 Katherine's Way (Female) Ext.1 Immanuel House (Male) Ext. 2.