The Lazarus Project of Knoxville
Program Application (All Programs)
Legal Name: Client first nameClient middle nameClient last name
Which program track are you applying for: Radio buttons
Current Address: Client AddressClient CityClient StateClient Zip
Telephone where you can be reached: Client phone Are you a felon? CheckboxesTOMIS# if Applicable: Text field
Are you required to report to the Sex Offender Registry?Dropdown
DOB: Client birthdate SSN: SSN Marital Status:Client marital status
If you are LEGALLY married, please list the name of your legal spouse:Text field Race:Client race
Do you have a valid state ID or driver's license?Dropdown
Can you provide a copy of your birth certificate or social security card (even if it is a photograph)? Dropdown
Do you have a current capias/outstanding warrant in any county or state at this time? (Be honest, this does not disqualify you for admission, we could possibly help you with this.) Dropdown
If yes, please list the county, state and the charge: Text field
Were you recently released from jail on bond? Dropdown If so, please provide the bonding company:Text field
Occupation: Text field
Education (last completed):
Radio buttons
Currently in treatment or jail:
Radio buttons
If yes, where: Text field Anticipated release date: Date
Please describe the circumstances around the criminal charge (if any) that originally resulted in your current situation or incarceration (what happened... tell us your story... why are you in jail or how did you become addicted?):
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Do you currently receive disability benefits:
Radio buttons
If so, what is the monthly amount? $Text field
Are you documented with law enforcment as a violent offender:
Radio buttons
Do you have any gang affiliations:
Radio buttons
Have you ever been in the military:
Radio buttons
If so, what branch: Text field How Long: Text field
Were you ever dishonorbly discharged from military service:
Radio buttons
If so, for what reason: Text field
Do you struggle with substance abuse/drug addiction:
Radio buttons
If so, please answer the blue questions below:
Drug of choice:
Client substances of choice
How often: Text field
How much: Text field
How do you use it: Text field
When did you start using drugs: Text field
Last time you used drugs: Text field
Criminal History:
| Year |
Charge |
Sentence |
County/State Convicted |
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Text field |
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| Text field |
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Pending Criminal Charges:
Radio buttons
If yes, what are they? Text field
In what county: Text field Court Dates: Text field
Other upcoming court dates: Text field County: Text field
Regarding what charge: Text field
On Probation or parole:
Radio buttons
Radio buttons
If yes, assigned officer: Text field County/State: Text field
Do you have an attorney/public defender:
Radio buttons
If yes, attorney's name: Text field County: Text field
How many children do you have: Text field Please list their names if they are under the age of 18: Text field
Current Medical Diagnosis or Problems: Client health problems Client categories Other medical information: Text field
Do you have any urgent medical or mental health concerns that would need to be addressed within 24 hours of your admission? Dropdown If so, please describe the concern:Text field
Medications: If none, write NONE (please include any medications you are supposed to be taking but do not have access to): Medication
Have you been in any type of substance abuse treatment before:
Radio buttons
If so, please list the names of facilities and the year you received treatment below: (this does not disqualify you, be honest)
Text field
Have you been incarcerated (more than 6 months at a time) before:
Radio buttons
If so, please list the dates and names of facility along with the associated charge below:
Name of Facility: Text field Dates: Text field Charge: Text field
Name of Facility: Text field Dates: Text field Charge: Text field
Name of Facility: Text field Dates: Text field Charge: Text field
What do you see as your main obstacle in life? (Why are you wanting our services?)
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Describe yourself, what kind of person are you?
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Emergency Contact:
Text field
Emergency Telephone Number:
Text field
Emergency Contact Address:
Text field
Emergency Contact Relationship to You:
Text field
How long do you plan to stay at our facility? Text field
Do you understand and agree to participate in all activities and courses that are faith-based while a resident in our facility?
Radio buttons
What is your spiritual/religious preference?Dropdown
Do you agree to pay a weekly program fee of $200.50, a $500 deposit, and any other fees associated with services outlined in the Housing Guidelines (Arrangements can be made regarding the deposit, but must be made prior to admission)? Checkboxes
I understand I will be required to fully engage a minimum of 40 hours per week in a life skills/employment position (assigned by the program Employment Specialist) for the duration of the year program or as deemed appropriate for my specific, recommended treatment plan?Dropdown
Signature:Signature