Application | A Better Way Ministries

First name

Last name

Phone

Marital Status

Birthday

Month

Day

Year

Shirt Size

Shoe Size

Address

Name of Emergency Contact

How did you hear about ABWM?

Any pending legal matters?

What are your life controlling issues?

Have you had any prior treatment or attended any other programs for these issues? If yes, provide the name of the facility and why you left.

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

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

Are you currently involved in any legal matters such as pending charges, upcoming court dates, probation, parole, or other legal obligations? If yes, please explain in detail.

If you answered “Yes” to the previous question, please provide the following information:

Name of Probation Officer, Attorney, or Legal Representative:

Name of Probation Officer, Attorney, or Legal Representative:

Phone Number of Probation Officer, Attorney, or Legal Representative:

Phone Number of Probation Officer, Attorney, or Legal Representative:

Email of Probation Officer, Attorney, or Legal Representative:

Email of Probation Officer, Attorney, or Legal Representative:

Address of Probation Officer, Attorney, or Legal Representative:

Address of Probation Officer, Attorney, or Legal Representative:

Do you have any diagnosed medical conditions? (Including STDs) If so, please explain.

Have you been diagnosed with any mental health disorders? (bipolar, schizophrenia, etc.)

Do you take any medications? (If so list all medications your currently taking)

How long have you been taking these medications (together or individually)

How do you plan on paying for medication while at ABWM?

Are you able to perform manual labor?

Yes

Do you have any physical limitations?

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

If you are not a Christian, do you identify with any other religion or belief system?

Can you read and write English?

Yes

What grade did you complete?

Are you willing to be mandated by the courts?

Yes

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

Yes

Who do you admire most in life and why? What has been your most pivotal life experience? What do you hope to accomplish at A Better Way Ministries?