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1 Men s Life Recovery Application Stage One Recovery Rockford Rescue Mission Ministries Date: IDENTIFICATION Rockford Rescue Mission 715 W. State Street Rockford, IL Fax: Name (Last) (First) (MI) Contact number: Alias/Nicknames: HOUSING Homeless? How Long? Reason? Hometown? County? DOB: Month Day 19 SSN: XXX-XX- (Last 4 ONLY) DL: # State ID: SS Card? Birth Cert. Yes No US Citizen? Veteran? Race: African American Multi Cultural Caucasian India Asian Indian American Other: Ethnicity: Non Hispanic Hispanic Military Branch: Is it a result of Domestic Violence? Yes No How long in Winnebago County? Number of times homeless? Address (if not homeless) ID s VERIFIED BY: BACKGROUND CHECK BY: Are you banned from any shelters? SEX OFFENDER CHECK BY: DATE: Attach Results RELATIONSHIPS Marital Status: Married Divorced Single Widowed Partner s name? Children? How many? Names & ages (list) Who cares for your children? How often do you see them? When did you last see them? Emerg. Contact: Name Phone Number Relationship Monthly Income: $ Rep Payee: FINANCIAL Sources: Unemployment SSI/SSDI Link Card? Monthly Pension Other Debts? List: Revised 6/2013 Page 1 of 5

2 For Office Use: Name: Date: Case Manager: Extension # HEALTH Dept. General Health Good Poor Medical Card Insurance Current Problem? Doctor Name: Provider Name: Prescription Meds? Describe: Scheduled Appointments? (list) Are you pregnant? List Meds: Date of Last Physical: Please circle any chronic illnesses that you have: STI/PID Eye Disease Coronary Artery Disease Emphysema Thyroid disease Ulcers Parkinson s Disease Stroke Migraine Headaches Gout Enlarged Prostate CHF COPD Asthma Sickle Cell Disease Cardiac Failure Diabetes Epilepsy/Seizure Disorder Glaucoma HIV/AIDS Pulmonary Disorder Crohn s Disease Lupus High Blood Pressure Cirrhosis Bronchitis Multiple Sclerosis Pneumonia Allergies Rheumatoid Arthritis Osteoarthritis Sleep Apnea Ulcerative Colitis Kidney Disease Tuberculosis Hepatitis GRAVIDA/PARA Cancer: (specify) Surgeries: MENTAL HEALTH Mental Health Issues? Diagnosis: Past Treatment? Diagnosis: Current Treatment? Describe: Taking Mental Health Meds? List Meds: Please circle any chronic illnesses that you have: Depression PTSD Anxiety Schizophrenia Bipolar Other: Using as Prescribed? MHP Name: Diagnosed Mental Disability? Family History of Mental Health Issues? Appointments? (list) Diagnosis: Describe: ADDICTIONS Date Last used Alcohol: Date Last used Drugs: Drug of Choice: Frequency of Use? Past Treatment or Detox? How Many Times? What? What? List other Drugs Used: List Places and Approximate Dates Attend AA? How Often? AA Sponsor? Other Support Group? Where? How often? Revised 6/2013 Page 2 of 5

3 LEGAL ISSUES Current Legal Issues? Charges? Court Dates: On Parole? Termination Date: Parole Agent: Paroled to Rockford? On Probation? Paroled From: Termination Date: Prob. Officer: Type of Prob.? Other Criminal History? SEX OFFENDER? ARSONIST? Winnebago County Offender Master ID #: Employed Where? List Previous Offenses, Sentence, Time Served, Where Served & Dates: EMPLOYMENT Unemployed Occupation/Skills: When last employed? EDUCATION Last Grade Completed: Year Completed: Diploma GED Certificate Degree: Functional Reader? / Writer? TRANSPORTATION & CLOTHING Vehicle Description: Own Vehicle Bus Walk Other Bicycle License Plate Number: CLOTHING NEEDS: Christian Other: Relationship with Jesus Christ What do you believe about God? SPIRITUAL CONDITION Don t Know Describe your spiritual condition: Church affiliation: I, (print), do hereby certify that the above information is true and accurate to the best of my ability. I understand false information may be cause for my immediate dismissal from the program. Signature Date Witness Date Revised 6/2013 Page 3 of 5

4 Question #1 Essay Questions Name: Why I want to be in the Men s Life Recovery Program? How/Where I learned about the Men s Life Recovery Program: Question #2 What do I expect it to be like in Men s Life Recovery Program? Revised 6/2013 Page 4 of 5

5 Essay Questions Page 2 Question #3 Name: What kind of person am I and how I feel about myself? Question #4 How did I get where I am in my life? Revised 6/2013 Page 5 of 5

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