APPLICATION FOR ADMITTANCE

Once you have filled out the application,  the next step is to call

(831) 372-2033 and schedule an interview.

We look forward to hearing from you.

Date: Date

PERSONAL INFORMATION

Name: Client first nameClient middle nameClient last name

Street Address: Client Address

City: Client City

State: Client State

Zip Code: Client Zip

Phone: Client phone

Email: Client email

DOB: Client birthdate

Age: Text field

Height: Text field

Weight:Text field

Gender: Client gender

Medications: Medication

Reason for medication: Text field

Allergies: Client allergies

 

EMERGENCY CONTACT
Contact

 

 

 

COURT INFO

Are you currently or have you ever registered as a sex offender in any state? Radio buttons

Have you ever been convicted of a felony? Radio buttons

If yes, give details (when, where, what):Paragraph

 

 

Do you currently have any current or pending court cases for anything? Radio buttons

If yes, which county? Text field

Details: Paragraph

 

Are you on or will you be on parole/probation/CDD? Radio buttons

If yes, why?Paragraph

 

Do you have any DUI’s in the past 10 years? Radio buttons

 

 

MEDICAL INFO

How would you rate your health? Text field

Are you currently under the care of a doctor? Radio buttons

If yes, why? Paragraph

Do you have any medical conditions that would preclude you from working in an environment that requires lifting over 50 pounds or more? Radio buttons

If on medication, did you list on last page? Radio buttons

(For Women) LMP Date? Date

 

PERSONAL INFO (CONTINUED)

Are you currently Checkboxes 

Other: Text field

 

 

Driver’s License #: Text field

State Issued: Text field

Exp. Date Date

If none: Checkboxes

Other? Explain: Paragraph

Marital Status: Client marital status

Children? Radio buttons

Ages: Text field

Do you currently have any CPS cases? Radio buttons

If yes, which county: Text field

 

 

 

EDUCATION

EducationHistory

Special Training:Text field

 

FINANCIAL AND INSURANCE INFO

Are you receiving financial assistance? Radio buttons

If yes, how much per month? Text field

What is the source? Text field

Do you receive EBT? Radio buttons

Do you have health insurance?Radio buttons

If yes, name provider: Text fieldInsurances

 

SUBSTANCE ABUSE HISTORY

Do you have a substance abuse problem? Radio buttons

Substance(s): Client substances of choice

 

Do you have problems sleeping? Radio buttons

Do you currently suffer from visual hallucinations? Radio buttons

Do you currently suffer from auditory hallucinations or hear voices? Radio buttons

Depression? Radio buttons

Anxiety? Radio buttons

Have you ever been diagnosed with a mental illness? Radio buttons

If yes, what was the diagnosis? Client diagnosis

When is the last time you were under care for mental illness? Text field

 

Do you know or have you known anyone that was in The Bridge Program? Radio buttons

If yes, what’s your relationship to them? Text field

Have you previously applied with us? Radio buttons

Have you been in any other programs? Radio buttons

If yes, list program name(s) and location(s): SoberLivingHistory

 

 

 

FAITH BACKGROUND

Church affiliation:Text field

Denomination preference:Text field

What would you like us to know about you? Paragraph

 

 

If you are currently incarcerated and are applying for Bridge residency, please fill out the following section:

Time in custody: Text field

Estimated release date: Date

Parole board hearing date: Date

ID#: Text field

Institution: Text field

Housing location: Text field

City: Text field

State: Text field

Zip code: Text field

 

 

 

REMINDER:

AFTER you have filled out the application, the next step is to call (831) 372-2033 and schedule an interview. We look forward to hearing from you.

ALL APPLICANTS

Please read and initial the following statements:

I understand that The Bridge is a minimum 12-month program. (Initials) Initials Text field

I understand that The Bridge is a non-smoking/vaping program. (Initials) Initials Text field

I understand that there are no new romantic relationships while in The Bridge program. (Initials) Initials Text field

I understand that The Bridge is a working program. (Initials) Initials Text field

I understand that I will not be paid in the Bridge’s working program. (Initials) Initials Text field

I understand that there is an initial 45-day minimum blackout period. (Initials) Initials Text field

I understand that worker’s phase begins after month 10 at the program and milestones met. (Initials) Initials Text field

I understand that I cannot have a 290 registration in my background. (Initials) Initials Text field

To the best of my knowledge, I have no outstanding court cases in any other county. (Initials) Initials Text field

To the best of my knowledge, I have no outstanding CPS cases. (Initials) Initials Text field

I acknowledge that I have read and understand the program policies listed above. (Initials) Initials Text field

 

 

 

 

MEMORANDUM OF UNDERSTANDING

I understand that The Bridge Restoration Ministry (TBRM) is a charitable, Christian organization, dedicated solely to the spiritual regeneration of persons, such as myself, who are in need of assistance in their spiritual, social, and physical rehabilitation. I recognize my need for assistance, and herby apply for admission to TBRM.

I understand that, upon entry into the program, I am responsible for the payment to TBRM of a one-time program administration fee of $500. Thereafter, upon entering Worker’s Phase of the program, in which I gain employment and income, I agree to pay TBRM a program fee of $500 for each month I remain in the program with employment, until the total program fee of $1,000 is satisfied. The total financial obligation I am agreeing to satisfy is, therefore, $1,500 for the entire 12-month program.

I understand that this is a 12-month (minimum) program, and I agree to commit myself to the 12 months required. At the end of 12 months, I will be evaluated by the Executive Director to determine if more discipleship training is needed. During the course of the 12 months, if I should leave the program and then return, my program may start over, as determined by the Executive Director.

I authorize investigation of all statements contained in this application as may be necessary for the Executive Director to make a decision concerning my acceptance into the program. In the event I am accepted, I understand that should any false or misleading information given in my application, or in my interview, come to light, my discharge from the program may result.

I acknowledge and agree that while at TBRM, I am not an employee and, therefore, not entitled to any form of wages, benefits, or compensation. I also understand that, as a part of TBRM recovery program, there is a vocational training stage, the purpose of which is to teach basic life skills which will be of benefit to me in obtaining and maintaining a job (after my time in the
program). There are no wages, benefits, or compensation paid to me by TBRM in this vocational training.

I agree to allow TBRM to use photographs of me in any of its publications.

As a condition of my admission, I agree to regularly attend services and Bible classes as arranged for or conducted by the ministry.

I further agree to abide by all of the program’s rules, regulations, and guidelines and any such that may be adopted during my residence at TBRM.

 

 

 

Upon entering the Worker’s Phase of the program, in which I gain employment and income, I agree to pay TBRM a program fee of $500 for each month that I remain in the program with
employment.

The information I have finished above is true and correct. I further acknowledge and agree that, if I am on parole or probation, all aspects of my participation at The Bridge may be disclosed to my parole/probation officer.

I have read the Memorandum of Understanding and understand the rules and regulations of The Bridge Restoration Ministry, and agree to abide by them.

Print Name: Text field

Signature: Signature

Date: Date

 

All sections must be completed.

Any false, incomplete, or misleading information provided above, or subsequently, may result in termination from The Bridge Rehabilitation program.

AFTER you have filled out the application, the next step is to call (831) 372-2033 and schedule an interview. We look forward to hearing from you.

DO NOT call the Executive director’s cell phone to make an appointment.

Please not he will only answer scheduled calls Monday-Thursday between 8am-4pm.