First Name *

Last Name *

Email *

Do you currently attend church or any type of group Bible study? *

Have your parental rights been terminated? *

If not, will you be seeking (check all that apply): *

Currently, children are in the care of: *

If so, what City and State? *

Marital Status *

If married, how does your husband feel about your involvement and time committment to this program? *

Is/was your husband a participant or enabler in your previous criminal activities? *

If yes, explain. *

RECOVERY: Are you participating in/attending a recovery group? *

Name/Location of Program *

How often do you meet? *

Name of the group facilitator *

RELATIONSHIPS - Are you currently dating or in an intimate relationship? *

If yes, please explain. *

HEALTH - Do you currently take prescription medication? *

If yes, list all medications and reason prescribed. *

Please list any mental health diagnosis received. *

Prescribing Physician: *

Are you currently employed? *

Company Name and location: *

Position *

If not employed, how are you supporting yourself? *

Are you looking for work? *

If not, please explain. *

Are you currently attending school? *

Certificates received *

Signature (By typing your name here, it is considerd the same as your signature on this form.) *

Date: *