Ready to make a change?Fill out the application below. Name * First Name Last Name Date of Birth * MM DD YYYY Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Phone * (###) ### #### Marital Status * Married Single Divorced Widowed Do you have any children? If so, please list their names and ages. Are any of your children in DSS custody? If so, where? Name and Phone Number of Case Worker (if applicable) Who is caring for your children? Are you able to pay the nonrefundable entry fee of $600? * This is your first 4 weeks of the program. Yes No When could you move in? * MM DD YYYY HISTORY OF ADDICTION AND SOBRIETY How long have you been sober? * Most recent rehabilitation program attended (if any) Please list any substances that you have been addicted to in the past and the date last used. * Name and phone number of sponsor * Why should you be selected for our sober living program? * Please list 3 things below that you would like to change in your life with the help of God and this program. * Are you willing to work to pay for the program residency fees? ($150 per week) * Select one. Yes No CURRENT EMPLOYMENT Employer/Company Name * Employer Email Employer Phone * (###) ### #### Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Pay * If on salary, add your annual salary. If hourly, add your hourly pay. Job Title and Responsibilities * Start Date and End Date (if applicable) * Reason for Leaving (if applicable) EMERGENCY CONTACT Emergency Contact Name * First Name Last Name Relationship to You * Emergency Contact Email Emergency Contact Phone * (###) ### #### Emergency Contact Name First Name Last Name Relationship to You Emergency Contact Email Emergency Contact Phone * (###) ### #### LEGAL HISTORY Are you a registered sex offender? * Yes No Are currently on probation/parole? * Yes No If yes, list the name and number of your probation/parole officer. Do you have a valid driver's license? * Yes No Driver's License Number and State * Do you have reliable transportation? * Yes No If yes, list the vehicle make, model, and tag number. Insurance Policyholder Insurance Policy Number HEALTH HISTORY Do you have physical conditions or disabilities? * Yes No If yes, please explain. Have you been diagnosed with any mental health disorders? If yes, please explain. * Are you currently working with a mental health practitioner/psychiatrist/counselor? * Yes No Are you currently taking any prescription medications? * Yes No If yes, please list the name, dose, and frequency of each medication. Do you have any physical limitations or disabilities? * Yes No If yes, please explain. DISCLAIMER/WAIVER I understand that Love Well Ministries is not a detoxification facility. * Yes No I understand that Love Well Ministries is not a medical program. * Yes No I understand that Love Well Ministries does not pay for medications. * Yes No I understand that Love Well Ministries is not a licensed treatment center and I waive my right to legal action against Love Well Ministries, it’s staff or volunteers based on any counsel I receive. * Yes No Signature * I, the Applicant, certify that my answers are true and honest to the best of my knowledge. If this application leads to my being accepted into the program, I understand that any false or misleading information in my application or interview may result in my relationship with Love Well Ministries being terminated. First Name Last Name Thank you!
