Name: Client first nameClient last name

Phone Number: Client phone

Email: Email field

Prefferred Method of Contact: Text field

Are you currentky taking any medications? Medication 

Are you disabled or on disability? If yes, please explain Text field

Can you work a full time job?

What life controlling issues are you struggling with that you think we could help you resolve? Paragraph

What substances are you currently using and how often do you use them? Text field

Are you willing to commit 12 months of your life to this program? Text field

Are you willing to commit to our Christ centered discipleship program to help you overcome life's hurts, habits and hang-ups? Text field

On a Scale of 1 to 10 how ready are you for a life change? Number field

Please explain why we should take you into our recovery program. Paragraph

Is there anything else that you would like to say regarding your application? Paragraph

What date would you like to enter TFH? Date

Signature:Signature