Reentry & Aftercare Application

Preliminary Reentry & Aftercare Resident Application

Dear Applicant,

Thank you for taking the time to apply to the FreedomWorks Reentry & Aftercare program. Please
follow the instructions below and thoroughly and thoughtfully fill out the application.


Step One:
-Review the FreedomWorks Reentry & Aftercare Covenant Agreement.
-Review the Release of Information Authorization Form.
-Review the Financial Responsibilities and Miscellaneous Information documents.
If you agree to the standards set forth in the Reentry & Aftercare Covenant Agreement, will sign
the Release of Information Authorization Form, and accept the terms of our Financial
Responsibilities and Miscellaneous Information policies, then proceed to the next step.
Step Two:
-Fill out the FreedomWorks Reentry & Aftercare Resident Application.
We cannot process your application until all the documents in this packet are complete. Failure to
provide the requested information will delay the screening process and you may not get an
interview or accepted into the FreedomWorks program.
Step Three:
-Submit the application packet here.


After we receive your completed application packet, you will be entered into our processing
system and notified of your review status within two weeks.

FreedomWorks Reentry & Aftercare
Phone: 612.522.9007 (Office) 612.588.9917 (Fax)
Email: case.manager@myfreedomworks.com Website: www.myfreedomworks.com
Mailing Address: PO BOX 11175, Minneapolis, MN 55411
Residence: 2929 Emerson Ave North, Minneapolis, MN 55411

 

Before completing the application, please read through the following:

FINANCIAL RESPONSIBILITIES
Security Deposit Return Policy
FreedomWorks will return the $400 Security Deposit only when you meet the following criteria:
1. Participate at FreedomWorks a minimum of 6 months.
2. Provide a written 30-day notice to leave FreedomWorks on or before the first day of a month prior to moving out.
(i.e.: notice on or before April 1 to leave on May 1) The full financial obligation must accompany the notice. Proper
notice and the final month’s payment must be made on time.
3. Be financially responsible for any damages that you caused to the building or property beyond normal wear and tear.
4. Clean out the entire living unit, including closets, carpet and window treatments, bathroom and kitchen, including
refrigerator and stove, must be cleaned, in cooperation with your apartment mates.
5. Pay all late charges or delinquent financial obligations in full.
6. Properly dispose of any debris, rubbish and discards that you do not take with you.
7. Return all keys. There is a $25.00 fee for each non-returned key.
8. Provide a forwarding address for FreedomWorks to mail the full/partial security deposit to you within two weeks.
60% Payment Policy
We understand that most men will come to FreedomWorks without much money or income. Because of this, we will
allow you to pay 60% of what you have when you come in and 60% of any money you take in during the following
month. This money will be put on hold in your name. You will be expected to provide copies of your check stubs.
In the meantime, we will keep track of what you owe to FreedomWorks. When you arrive, your account will be
charged $400 for a Security Deposit and a portion of the $400 monthly obligation based on the number of days in your
first month. The account will also be charged the $400 obligation each month following.
Once you have employment, you can apply for Emergency Assistant from Hennepin County. This process will take some
time. Any money that comes through this (which could be up to $800) will be credited to your account.
After Emergency Assistance has been granted/denied, the money you have put on hold goes towards the amount you
still owe on your account; any excess amount left on hold will be returned to you.
Late Payment Policy
If you are unable to pay your monthly financial obligation on time, there is a late fee of $5 per day charged to your
account until the total amount due is paid in full. It is possible to avoid paying the late fee by presenting a thoughtful
and thoroughly written Late Payment Plan (LPP). The LPP must be submitted 2 days prior to when your payment is due.
Submitting a LPP does not guarantee approval and if approved it is valid for only one month.
Requirements of the Late Payment Plan:
-Drafted by you and submitted to the Administrative Coordinator.
-Describe the reason(s) that your financial obligation will be late, and explain the circumstances surrounding the
default that are out of your control (lay-off, a large unexpected expense, etc.).
-Create a timeline showing how and when you will bring your account up to date.
-Include copies of your check stubs and any other relevant documentation to support your situation (child support
payments, car insurance bill, phone bill, etc.)
-Develop a feasible budget and provide a copy.

MISCELLANEOUS INFORMATION
Release of Media Information
FreedomWorks requires you sign a media release that authorizes the organization to use photographic images taken of
you, videos, and portions of your story for the purpose of publication, promotion, and illustration in any manner or in
any medium.
Items Brought Into the Facility
Staff inspect all used items of clothing, bedding, linens, pillows etc. prior to bringing them into the facility. We ask you to
prearrange a time to get the items inspected. Items purchased from second-hand/thrift stores, garage sales, received
from friends and family, or brought from a personal storage locker must go through the FreedomWorks clothes dryer
and get heat treated before they enter the resident’s apartment. All non-inspected items are quarantined in the laundry
room until residential staff approves them.
-Brand new clothing items that are from FIRST SALE retailers are OK if the item has an original price tag.
-No furniture or electronics are allowed into the building without prior approval.
-The FreedomWorks House Manager will routinely check for restricted and unfamiliar items during regular house
inspections. Any items that do not meet this policy are removed immediately.
Visitors to the Facility
Visiting Policy
-NO VISITORS DURING PROGRAMMING.
-Residents must be with visitors at all times
Unemployed resident visiting times:
-Monday thru Thursday from 4:30 pm to 10:00 pm. (Except during Programming)
-Friday from 4:30 pm to 11:00 pm. (Except during Programming)
-Saturday from 9:00 am to 11:00 pm (Except during Programming)
-Sunday from 9:00 am to 10:00 pm
Employed residents visiting times:
-Monday thru Thursday from 8:00 am to 10:00 pm (Except during Programming)
-Friday and Saturday from 9:00 am to 11:00 pm (Except during Programming)
-Sunday from 9:00 am to 10:00 pm

Any visiting outside of these times must be approved ahead of time by staff.

FreedomWorks staff use of the community room for various reasons throughout the week and will be given
priority.


Upon arrival to FreedomWorks, you will be required to sign a form indicating that you have read,
understand, and will abide by the Financial Responsibility and Miscellaneous Information policies.

 

Date of Application     Date   Desired move-in date Date

Personal Information

First Name    Resident first name 

Middle Name Resident middle name      

Last Name Resident last name

 

Date of Birth Resident birthdate

Gender Resident gender(We are only able to provide housing for men at this time.) 

Email Resident email

Phone Resident phone

Mailing Address Resident mailing address

Do you own your own vehicle? Checkboxes  Year/Make/Model Text field  License Plate Number Text field

Do you have a valid drivers license? Checkboxes  State Text field  License Number Text field

Who told you about FreedomWorks? Client referral source

Criminal History

Due to insurance restrictions, those convicted of level three sexual offenses and/or arson are not eligible to be part of
FreedomWorks. All information must be filled out.

 

Supervised Release Date (SRD):Date

Expiration Date: Date

Conditions of release Paragraph

Convictions(s):Text field Date: Date

Convictions(s):Text field Date: Date

Convictions(s):Text field Date:Date

Current County of commit:Text field Are you on Intensive Supervised Release? Checkboxes

Do you have any current or pending charges? Text field

Case Worker's name Contact 1 name  Phone: Contact 1 phone Email: Contact 1 email Please enter "caseworker" here>Contact 1 type

Parole/Probation Officer's name Contact 2 name Phone Contact 2 phone Email: Contact 2 email Please enter "PO" here>Contact 2 type

Medical History

You must sign a release of medical information form prior to an interview for possible acceptance into FreedomWorks,
which allows FreedomWorks to communicate with medical personnel in emergency cases or for other reasons relevant
to your consideration for the program. All information must be filled out.

Doctors name: Contact 3 name Please enter "Doctor" here> Contact 3 type

Names of prescription medications you are currently taking:

1) Medication 1 name

2) Medication 2 name

3) Medication 3 name

4) Medication 4 name

Have you ever been treated for mental health issues? Checkboxes

If yes, please list dates, locations and the conditions you were treated forParagraph

Addictions

Have you even been addicted to any form of drugs or alcohol? Checkboxes

Date of last alcohol or drug use: Recovery history 1 sobriety date

List your drug(s) of choice: Paragraph

Have you ever been a patient in a chemical dependency treatment program? Checkboxes   Date: Date

Program Name:Treatment center 1 name City:Treatment center 1 city Did you complete it? Checkboxes

Program Name: Treatment center 2 name City: Treatment center 2 cityDid you complete it? Checkboxes

Program Name: Treatment center 3 name City: Treatment center 3 cityDid you complete it? Checkboxes

 

Addictive Behaviors

(co-dependency, overeating, spending, sex, impulsive behavior, etc)

List your addictive behaviors: Paragraph

Have you been treated for your addictive behavior(s)? Checkboxes

Do you feel you need treatment for an addiction? Checkboxes

 

Support

(Sponsor, accountability partners, mentor, others)

Person/Group: Contact 3 name Please enter the type of your relationship here> Contact 3 type

Person/Group: Contact 4 name Please enter the type of your relationship here> Contact 4 type

Person/Group: Contact 5 name Please enter the type of your relationship here> Contact 5 type

 

Employment

Do you have a resume? Checkboxes

Most recent jobs: 

Employer: Employer 1 name Position: Employment 1 position

Employer: Employer 2 name Position: Employment 2 position

Employer: Employer 3 name Position: Employment 3 position

Professional Skills: Text field

What type of job and career would you like to pursue: Paragraph

Education

Do you have a high school diploma Checkboxes GED? Checkboxes Date received: Date

Do you have a College degree? Checkboxes College Credits: Text field Date Received: Date

List the classes you have completed while incarcerated:Paragraph

Faith Journey

List activities involving faith that you are currently involved in: Paragraph

Describe your faith journey: Paragraph

Goals and Action Plans

Faith Action Plan: Text field

Recovery Action Plan: Text field

Employment Action Plan: Text field

Reconciling with family Action Plan: Text field

Other goals: Text field

Other Goals Action Plan: Text field

Why are you interested in participating in FreedomWorks?Paragraph

What are your other alternatives for housing? Paragraph

Write a brief story of your upbringing:

 Paragraph

Paragraph

Personal Assessment

Do you have a valid MN drivers license? Checkboxes

If not, what is your action plan to make it valid? Text field

Do you owe community service? Checkboxes Number of hours: Text field

Do you owe restitution? Checkboxes Amount: Text field

Have you been involved in a gang? Checkboxes Are you currently involved in a gang? Checkboxes

Do you have personal challenges living in North Minneapolis? Checkboxes

If so, what are they? Text field

Marital Status: Client marital status

Number of children: Text field Child support in place: Checkboxes

Do you owe arrears? Checkboxes  Amount: Text field

References

Provide names and contact information for at least two people from this list that will provide a reference for you.

(Biblical counselor, caseworker, chaplain, pastor, mentor, Bible study leader, job supervisor, program staff person)

Name: Contact 6 name Phone: Contact 6 phone Email: Contact 6 email Type:Contact 6 type

Name: Contact 7 name Phone: Contact 7 phone Email: Contact 7 email Type: Contact 7 type

Name: Contact 8 name Phone: Contact 8 phone Email: Contact 8 email Type: Contact 8 type

Name: Contact 9 name Phone: Contact 9 phone Email: Contact 9 email Type: Contact 9 type

Emergency Information Contact

(Family or close friend)

Name:Contact 10 name Phone:Contact 10 phone Email: Contact 10 email Type: Contact 10 type 

Covenant Agreement

Please carefully read through this covenant and sign to confirm your agreement

FREEDOMWORKS REENTRY & AFTERCARE COVENANT AGREEMENT


If you will worship God with your life, you will experience a peace, a joy and a contentment that can only come from
knowing Him.


The purpose of this covenant is to help you, the resident, grow closer to God through His Son Jesus Christ by
following basic biblical principles in; accountability, transparency, and community through new relationships in
Christ.


We want to help you develop the disciplines that will enable you to live an abundant life in Christ. As staff, our call is to
assist Him in doing this by guiding you in new relationships and support systems in a safe encouraging living
environment, as well as, offer direction to other services whenever possible. When you graduate from FreedomWorks,
you will be trained up in Christ, have a solid Christ-Centered support system and gained independence that will make it
possible for you to support yourself spiritually and financially when you leave FreedomWorks.


I agree to participate in the FreedomWorks programs for at least six months unless I am terminated in accordance with
the terms stated in this covenant agreement. If I decide to leave after six months, I must submit a written notice.

I understand that I will owe FreedomWorks the monthly financial obligation through the end of the next full month.
(i.e.: With notice given on May 1st, the financial obligation is owed through the end of May. With notice given on May 3rd
, the financial obligation is owed through the end of June.)

I agree to pay the FreedomWorks monthly financial obligation
- $400 for a shared unit for 90 days
- $450 for a shared unit from 90 days to 6 months
- $500 for a shared unit 6-8 months or single unit moved into until 8 month period.
- $550 for a shared or single unit after 8 months while participating in the Reentry & Aftercare program.

I agree to pay an initial security deposit of $400. I also agree to add to that security deposit as the monthly
obligation increases.

I agree to share in the care and maintenance of the FreedomWorks building as requested and to do assigned tasks on
Thursday Night Connection nights. I also agree to do assigned jobs at outreach functions on or off campus. I will be
accountable to the FreedomWorks staff and/or appointed persons for my work assignments. 

I understand that $100 will be credited towards my monthly financial obligation to FreedomWorks if I complete the
tasks previously described. Warnings will be given for not completing the assigned tasks. Upon the third violation within
a 30-day period, I will be required to pay the $100 myself. 

I understand that I will potentially be sharing a room with one other program participant. I also understand that my
ability to move into a single room is a privilege that is earned and will only occur after FreedomWorks staff has
determined that I have earned that privilege. 

I understand that FreedomWorks is NOT housing. 

I agree to provide a urine analysis (UA) upon entering FreedomWorks’ Resident Discipleship Program. I also agree to
provide UA’s at staff’s request. (UA’s must be given within one hour of request or it will be considered positive. A
positive UA can result in immediate termination. Once a UA has been requested, residents cannot leave the main floor
until the UA has been provided). 

I understand that FreedomWorks desires to be a smoke-free ministry. If I do smoke, I agree to smoke only at designated
times and locations either on the property or at any program event.

I will not use any beverages containing alcohol (beer, wine, or spirits) or abuse any non-prescription drugs at any time
while at FreedomWorks. 
I agree to inform FreedomWorks staff of any medications that I have been prescribed before and during my stay at
FreedomWorks. I also agree to sign a release of medical information prior to moving into the FreedomWorks
apartment. I agree to inform FreedomWorks staff of any medications due to mental illness and the name of the
medication and the prescribing doctor’s name. 

I agree to make all curfew times while I am at FreedomWorks. I further agree to get permission from the designated
staff person before making any commitments to overnight elsewhere. I understand that my key will be deactivated if I
miss a curfew. 

I understand that female guests are not allowed in residents’ apartments at FreedomWorks. All visiting will be held in
the Welcome Back Center. Only FreedomWorks residents are allowed to stay overnight. 

I agree not to be involved in a relationship that will hinder my relationship with Christ. If I do become involved in an
unhealthy relationship, I may be asked to end the relationship as a contingency to remain at FreedomWorks.

I agree to comply with all requirements of Phases 1 through 4. I understand that failure to comply with these
requirements may result in immediate termination.

I agree to meet one-on-one with my biblical mentor weekly. If I do not have a mentor, I will accept the mentor
FreedomWorks assists in providing. I also agree as part of my participation that my mentor will be assuming the role of
holding me accountable towards fulfilling and completing the FreedomWorks Phases. 

I agree to build, maintain and follow a monthly budget plan while at FreedomWorks.

I agree to obtain suitable, full-time employment within one month of residing at FreedomWorks. I agree to comply with
the daily Employment Verification Sheets (EVS) until I find full-time employment. I also know that failure to comply with
terms of seeking employment and/or EVS will be grounds for termination from FreedomWorks.

I agree to participate in all required activities of the FreedomWorks Ministry. 

I understand that FreedomWorks s reserves the right to make changes and or adjustments to the covenant as needed.

I, (Enter Name) Text field, have read and understood the above Covenant. It is my desire to abide
by the terms set forth in this agreement during my stay at FreedomWorks. I also understand that not keeping this
covenant will mean termination from FreedomWorks, in which I will be asked to return my keys and to leave
immediately. If terminated, I will have 24 hours to gather my personal property. If personal property is not picked up
within 24 hours, it will be put in storage and I agree to pay any storage and any associated fees in order to get my
property back.


Signature Signature Date Date

Risky Relationships, Places and Behaviors

People you need to stay away from: People that either trigger you towards relapse or enable you to in live an unhealthy
lifestyle. (We are not looking for general titles: drug dealers, bartenders etc… We are looking for specific first name and
last initial).
1.Text field
2.Text field
3.Text field
4.Text field
5.Text field
6.Text field
7.Text field
8.Text field
Places you need to stay away from: These are parts of town that promote relapse, trigger old behaviors and lifestyle;
and are most likely associated with the names above.
1.Text field
2.Text field
3.Text field
4.Text field
5.Text field
6.Text field
7.Text field
8.Text field
Behaviors you need to stay away from. These are unhealthy attitudes, emotions or impulses when displayed could lead to relapse.
1.Text field
2.Text field
3.Text field
4.Text field
5.Text field
6.Text field
7.Text field
8.Text field
People that should be contacted when you are involved in any of the above:
1. Name:Text field Relationship: Text field Phone:Text field
2. Name:Text field Relationship: Text field Phone:Text field
3. Name:Text field Relationship: Text field Phone:Text field
4. Name:Text field Relationship: Text field Phone:Text field
5. Name:Text field Relationship: Text field Phone:Text field
6. Name:Text field Relationship: Text field Phone:Text field                                            

In the area under your signature below, please write out You Story!

Release of Information - By signing below, I authorize FreedomWorks staff to: 

Speak to individuals, referrals and agencies regarding my application to FreedomWorks

as well as to receive and review my physical/mental health and probation/parole records.

I understand that:
1. My health information is protected by Federal Confidentially Rules (42 CFR Part 2; and/or HIPAA, 45 CFR) and state privacy laws, and disclosure is allowed only with my authorization except in limited circumstances as outlined in FreedomWorks policies. I also understand that I have the right to inspect and receive a copy of my treatment records that may be disclosed to others as provided under applicable state and federal laws.
2. I can revoke this authorization in writing at any time by providing written notification to FreedomWorks, except to the extent that action has been taken in reliance on it. This authorization will expire two years from the date below unless I request an earlier revocation in writing.
3. Communications resulting from this authorization will reveal that I have received or have attempted to receive services at FreedomWorks.
4. Federal confidentiality regulations prohibit disclosure of information.
5. While participating at FreedomWorks I cannot revoke the authorization release of information. I can, however, revoke this authorization upon leaving FreedomWorks.

By continuing, you agree that your electronic signature is the legally binding equivalent to your handwritten signature. Whenever you execute an electronic signature, it has the same validity and meaning as your handwritten signature. You will not, at any time in the future, repudiate the meaning of your electronic signature or claim that your electronic signature is not legally binding.

SignatureSignature

DateDate       

My Story

What led me to my current and past incarcerations

Paragraph

Paragraph

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