Please fill out the application and fax or mail back to us. Our receipt of your application does not guarantee a bed date or acceptance.

Transcription

1 Dear Applicant: Attached is the application you requested for Paducah Lifeline Ministries or Ladies Living Free. We are delighted you have chosen our facility and look forward to assisting you on your journey to freedom in a new life in Christ. Please fill out the application and fax or mail back to us. Our receipt of your application does not guarantee a bed date or acceptance. The next client intake will be in the month of. All clients are interviewed before they are accepted. Please call our office during the first week of to request an interview with the director. If accepted, you will be notified in writing and will receive additional information regarding the intake dates and deposits due. God bless you and we look forward to hearing from you. Sincerely, Paducah Lifeline Ministries and Ladies Living Free

2 - APPLICATION FOR ADMISSION Date Name Present Address Permanent/Home Address Phone Number(s) Date of Birth Gender: Male Female Date Available for Program Are you a citizen of the United States? Emergency Contact Information Name Relationship Address Phone(s) Release of Confidentiality Intake Deposit of $50 is due upon acceptance. Intake Fee Balance of $550 is due the day of arrival. All fees are non-refundable. Please return application along with a copy of your national criminal record report and a letter stating why you want to enter the program. Additional information (ie., legal, medical, etc.) may be required before acceptance is considered or confirmed.

3 Family Information Marital Status: Single Married Common Law Divorced Widowed Remarried Spouse ge: List your dependant children and their age: Do you have a boyfriend/girlfriend or fiancé Name Have you ever engaged in homosexual activity? Age Health and Medical What is the condition of your health? Excellent Good Fair Poor Critical Do you have any type (Students will be required to submit to a physical, so please be honest.) If so, has it left you with a weakness of any sort? Have you ever been If yes, briefly describe: Do you take medication or need medical attention regularly? If yes, list below all medications you are currently taking below (use separate sheet if necessary): Medication Reason taking Dosage How long taken Who were these medications prescribed by? Name Phone#

4 Do you have any activity restrictions due to a medical condition? If yes, please describe. Do you receive Disability or SSI Income? If so, how much? Please list any allergies: When was your last physical examination? Have you ever received treatment or counseling for emotional, mental, or psychological conditions? If yes, list dates, counselor or physician, and the reason: List all medications you are allergic to: Do you have insurance of any type? (Medical/Dental/etc.) If yes, list the name of the provider, their address, phone number and policy number: Personal Record of Conduct Have you ever used prescription drugs for other than medical purposes? If yes, what drugs and how long? Check all drugs used: Marijuana/Pot Cocaine Amphetamines LSD Barbiturates Alcohol-Heavy Use Alcohol-Light Use Methadone Heroin Inhalants (Glue, Gas, Etc.) Morphine STP PCP (Angel Dust) Speed (Any Type) Crystal Meth. What is the first drug you used? Beginning at what age? What is the main drug you used? How long? How much time/money was spent on drugs each day? What drugs have you injected? Do you smoke/use tobacco? If you have been incarcerated and/or have been are you willing to discontinue tobacco use? Have you ever had a severe emotional breakdown? If yes, when?

5 Have you ever attempted to commit suicide? If yes, when? How? Why? Have you ever had any psychotherapy or counseling? If yes, by Whom? Address Education and Goals Do you have a high school diploma or GED? Please list any college, university, trade or technical school you have attended and the years attended: Have you ever been diagnosed with a learning disability? Church/Spiritual Background (Please be honest! Although Paducah Lifeline Ministries, Inc. is founded on the Holy Bible, not everyone who enters the program is a Christian.) Do you believe in God? Do you believe in the God in the Holy Bible? (Old and New Testament) If the answer above is no, please explain your beliefs: Do you believe Jesus Christ is the Son of God? What do you think the purpose of prayer is? What do you think the purpose of the Bible is? What do you believe about life after death? Who is responsible for the condition you are in? Do you consider yourself to be a Christian? If yes, briefly describe your experience of salvation:

6 Do you have a denominational preference? If so, which one? Have you ever been involved with the occult/witchcraft/etc.? If yes, briefly describe your involvement: In your own words, what do you think we can help you with? Is there any further information that you feel might help us in considering your application? Recovery or Rehab Programs(s) Have you ever been in a Recovery Program or Rehab before? Do you understand the purpose of Paducah Lifeline Ministries/Ladies Living Free? Do you have any responsibilities that would hinder your being in this program for 6 months? 12 months If yes, briefly describe: Employment Background Are you employed now? If so, where? Please list any skills you have: Legal Record Do you have any felony convictions? If so, please list each one and the county and year convicted. Do you have any cases pending? Charges? Disposition? Name of Judge Court and address Name of usual attorney:

7 Do you have any outstanding warrants? If yes, what is the reason? Are you currently on parole or probation? If yes, how long? Name of probation/parole officer: Par ne number: For Inmates Presently Incarcerated in Prison/Jail Name of Institution Institution Number Social Work Are you eligible for Shock Probation? Shock Parole? When do you appear before the board? Is this your first time? Name and Location of Institution Date Reason for Confinement Probation Parole Length of Confinement Record During Confine