Made For More Ministries, Inc

Residential Application

 

Personal Information

Date:Date

1. Full Name: Client first nameClient middle nameClient last name

2. Date of Birth: Client birthdate

3. Gender: Client gender

4. Address: Client Address

5. City/State/Zip Code: Client CityClient StateClient Zip

6. Phone Number: Client phone

7. Email Address: Client email

8. Social Security number: SSN

9. Driver’s License or ID number:Text field State:Client State

 

Emergency Contact Information

1. Full Name: Text fieldText field

2. Relationship to Applicant: Text field

3. Phone Number: Client phone

4. Email Address: Client email

 

Background Information

1. Current Occupation: Text field

2. Highest Level of Education Completed: Text field

3. Are you currently employed?  _Text field

If yes, please provide details: Text field

4. Have you ever been convicted of a sex crime? Text field

5. Do you have any felony convictions in the past 7 years?  Text field

   If yes, please provide details:

Criminal History

6. Are you willing to submit to a background check? Text field

7. Are you currently on parole or probation? Text field

  If yes, please provide your officers contact information:

  State and county: Text field

  Officers Name: Text field

  Officers phone number: Text field

  Officers email: Text field

8. Are you mandated to this program? Text field

  If yes, by what county? Text field

9. Are you currently under the care of a physician or mental health professional? Text field

   If yes, please provide details: Client health problems

10. Are you taking any medications? Text field

  If yes, please provide details: Client medical notes

Substance Use and Recovery History

1. What substances have you used in the past? Text field

2. When was the last time that you used and what substance? Text field

3. How long have you been struggling with substance use? Text field

4. Have you previously participated in any recovery programs?Text field

   If yes, please provide details: SoberLivingHistory

5. What steps have you already taken towards recovery? RecoveryHistory

6. What are your primary reasons for seeking recovery at this time? Text field

1. Are you currently affiliated with a faith community or church?Text field

   If yes, please provide details: Text field

2. How important is your faith or spirituality in your recovery process? Text field

3. Have you participated in any faith-based recovery programs before? Text field

   If yes, please provide details:
Text field

Program Commitment

1. Why are you interested in this particular faith-based recovery program? Text field

2. What are your personal goals for participating in this program? Text field

3. Are you willing to commit to attending all scheduled meetings and participating actively in program activities? Text field

4. Do you have any concerns or questions about the program that you would like to discuss before joining? Text field

Additional Information

1. Is there any additional information you would like to share that may help us better understand your needs and support you during your recovery journey? Text field

 

Agreement and Signature

I understand that providing false or misleading information on this application may disqualify me from participating in the program. I agree to be honest and forthcoming about my background and current situation. I also agree to adhere to the guidelines and expectations of the faith-based recovery program.

Signature: Signature

Date: Date

 

I desire to participate in a sober living community with Made For Ministries, Inc. Should I be accepted into the program, I release and forever discharge Made For Ministries, Inc. and any other ministry/organization involved and each of their respective members, employees, officers, directors, representatives and volunteers from any and all claims for any and all injuries, illnesses, losses or damages I might have in any way relating to involvement in the Made For Ministries, Inc. sober living community program.  I am eighteen (18) years of age or older, and this RELEASE is binding on me and my executor, administrators, and heirs. I have fully read and understand the above RELEASE. *

 

Signature: Signature

Date: Date