Application – A BETTER WAY MINISTRIES

Name *

First

Last

Address *

Phone Number *

Email *

Date of Birth *

Height

Format Example: 5' 11"

Weight

T-Shirt Size *

Marital Status *

Number of Children *

Emergency Contact *

First

Last

Emergency Contact Address *

Emergency Contact Phone Number *

Relationship With Emergency Contact *

Lawyer's Contact Information *

How did you hear about the ministry? *

What are your life controlling issues? (i.e. drugs, alcohol, sex, gambling, etc.) *

What drugs are you currently struggling with? *

When's the last time you've used and what was it? *

Have you had any previous treatments or attended programs for these issues? If yes, provide the name of the facility that you left. *

If you are incarcerated, please list your charges and/or convictions. *

Do you have any pending court cases or legal issues? If so, please explain. *

Are you a registered sex offender? If so, please explain and include any restrictions you may have. *

Have you been convicted of any violent crimes? If so, please explain. *

Do you have any diagnosed medical conditions? If so, please explain. *

Have you been diagnosed with any mental health disorders (bipolar, schizophrenia, etc.)? If so, do you take an medications and what are their names? *

Are you currently taking any prescribed medications? If so, please explain and list ALL of the medications.

How do you plan on paying for you medications while at A Better Way? *

Are you able to perform manual labor? *

Do you have any physical limitations? If so, please explain. *

Are you a Christian? If so, how long and what denomination? *

If you are not a Christian, do you identify with any other religion or belief system? (not being a Christian does not disqualify you) *

Can you read/write in English? *

What grade did you finish in school? *

Are you willing to complete 18 months or more at staff discretion? *

Are you willing to be mandated by the courts? *

Tell us who you admire most in life and why, what has been your most pivotal life experience, and what do you hope to accomplish at A Better Way. *

Name