Thank you for taking the time to apply to the FreedomWorks Reentry & Aftercare program. Pleasefollow 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 signthe Release of Information Authorization Form, and accept the terms of our FinancialResponsibilities 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 toprovide the requested information will delay the screening process and you may not get aninterview 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 processingsystem and notified of your review status within two weeks.
FreedomWorks Reentry & AftercarePhone: 612.522.9007 (Office) 612.588.9917 (Fax)Email: email@example.com Website: www.myfreedomworks.comMailing Address: PO BOX 11175, Minneapolis, MN 55411Residence: 2929 Emerson Ave North, Minneapolis, MN 55411
Before completing the application, please read through the following:
FINANCIAL RESPONSIBILITIESSecurity Deposit Return PolicyFreedomWorks 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. Propernotice 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, includingrefrigerator 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 PolicyWe understand that most men will come to FreedomWorks without much money or income. Because of this, we willallow you to pay 60% of what you have when you come in and 60% of any money you take in during the followingmonth. 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 becharged $400 for a Security Deposit and a portion of the $400 monthly obligation based on the number of days in yourfirst 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 sometime. 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 youstill owe on your account; any excess amount left on hold will be returned to you.Late Payment PolicyIf you are unable to pay your monthly financial obligation on time, there is a late fee of $5 per day charged to youraccount until the total amount due is paid in full. It is possible to avoid paying the late fee by presenting a thoughtfuland 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 thedefault 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 supportpayments, car insurance bill, phone bill, etc.)-Develop a feasible budget and provide a copy.
MISCELLANEOUS INFORMATIONRelease of Media InformationFreedomWorks requires you sign a media release that authorizes the organization to use photographic images taken ofyou, videos, and portions of your story for the purpose of publication, promotion, and illustration in any manner or inany medium.Items Brought Into the FacilityStaff inspect all used items of clothing, bedding, linens, pillows etc. prior to bringing them into the facility. We ask you toprearrange a time to get the items inspected. Items purchased from second-hand/thrift stores, garage sales, receivedfrom friends and family, or brought from a personal storage locker must go through the FreedomWorks clothes dryerand get heat treated before they enter the resident’s apartment. All non-inspected items are quarantined in the laundryroom 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 houseinspections. Any items that do not meet this policy are removed immediately.Visitors to the FacilityVisiting Policy-NO VISITORS DURING PROGRAMMING.-Residents must be with visitors at all timesUnemployed 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 pmEmployed 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 givenpriority.
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
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
Due to insurance restrictions, those convicted of level three sexual offenses and/or arson are not eligible to be part ofFreedomWorks. 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
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
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 relevantto 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
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
(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
(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
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
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
List activities involving faith that you are currently involved in: Paragraph
Describe your faith journey: Paragraph
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:
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
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
(Family or close friend)
Name:Contact 10 name Phone:Contact 10 phone Email: Contact 10 email Type: Contact 10 type
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 fromknowing Him.
The purpose of this covenant is to help you, the resident, grow closer to God through His Son Jesus Christ byfollowing basic biblical principles in; accountability, transparency, and community through new relationships inChrist.
We want to help you develop the disciplines that will enable you to live an abundant life in Christ. As staff, our call is toassist Him in doing this by guiding you in new relationships and support systems in a safe encouraging livingenvironment, 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 itpossible for you to support yourself spiritually and financially when you leave FreedomWorks.
Signature Signature Date Date
People you need to stay away from: People that either trigger you towards relapse or enable you to in live an unhealthylifestyle. (We are not looking for general titles: drug dealers, bartenders etc… We are looking for specific first name andlast initial).1.Text field2.Text field3.Text field4.Text field5.Text field6.Text field7.Text field8.Text fieldPlaces 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 field2.Text field3.Text field4.Text field5.Text field6.Text field7.Text field8.Text fieldBehaviors you need to stay away from. These are unhealthy attitudes, emotions or impulses when displayed could lead to relapse.1.Text field2.Text field3.Text field4.Text field5.Text field6.Text field7.Text field8.Text fieldPeople that should be contacted when you are involved in any of the above:1. Name:Text field Relationship: Text field Phone:Text field2. Name:Text field Relationship: Text field Phone:Text field3. Name:Text field Relationship: Text field Phone:Text field4. Name:Text field Relationship: Text field Phone:Text field5. Name:Text field Relationship: Text field Phone:Text field6. Name:Text field Relationship: Text field Phone:Text field
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.
What led me to my current and past incarcerations