Life Learning Center Candidate Intake Application

Select the agency or organization who referred you to Life Learning Center:*
List the agency or organization you were referred by:*
How did you hear about Life Learning Center?*
Select the judge who sentenced or recommended you to attend Life Learning Center:*
Which judge sentenced or recommended you to attend Life Learning Center:*
Please share how you heard about Life Learning Center:*
Person/Representative who referred you to LLC:*
REFERRAL SOURCE:

Life Learning Center Candidate Intake Application

Revised 2/17/21
IDENTIFYING INFORMATION:
Name*

PrefixFirst NameMiddle NameLast NameSuffix
Do you have a name that you preferred to be called?
Address*

Street Address

City

CountyState

Zip Code
Is the above address a sober living?

YesNo
Birth Date*

MonthDayYear
Age*
Social Security Number*
Gender*
Phone Number*
E-mail
example@example.com

EMERGENCY CONTACT:
Emergency Contact Name*
Relationship to Emergency Contact*
Emergency Contact Phone Number*
Does anyone have legal guardianship over you or your wages?*

YesNo
Explain:*

APPLICANT DEMOGRAPHICS:
Race:*

White/CaucasianBlack/African-AmericanAsian/Asian-AmericanHispanic/LatinxNative AmericanHawaiian/Pacific IslanderBi-Racial/Multi-RacialArab/Arab AmericanOther
Marital Status:*
Highest Level of Education:*
Highest Grade Completed:*
How many years of college did you complete?*
Area of Study:*
Military Service/Veteran:*

CRIMINAL HISTORY:
Do you have a criminal history of any kind and/or pending charges?*

YesNo
Complete the information below for each of your criminal charges/convictions:*
Insert "Other" charge(s):
Are you on probation/parole?*
Select "Pending" if you are awaiting probation/parole.

HOUSING & TRANSPORTATION:
Select the option that best describes your current housing situation:*
Do you consider your housing to be safe and stable?*

YesNo
Select the option that best describes your primary method of transportation:*
Do you have a valid driver's license?*

YesNo
Will you require transportation assistance during your time at LLC?*

YesNo

PRE-PROGRAM SELF-ASSESSMENT:

The Life Learning Center program addresses the five domains of life (physical, emotional, relational, financial, and spiritual) to promote hope and dignity amongst Candidates. Use the 1-5 scale to rank your current knowledge and/or functioning in each of the domains below.
1= Poor 2= Below Average 3= Average 4= Above Average 5= Excellent
Physical & Healthy Lifestyle- knowledge and practice of healthy lifestyle choices including fitness, nutrition, hygiene, and sleep*
Emotional- ability to identify, manage, and employ your emotions*
Relational- understanding of characteristics and boundaries that define a healthy relationship*
Financial- ability to manage your finances and follow a budget*
Spiritual- awareness and practice of personal beliefs to find meaning, connection, and value*
Hope- optimism and enthusiasm for the future*
Dignity- sense of self-worth, value, and importance*

PHOTO & MEDIA RELEASE:
Select one of the following regarding use of photo and media:*

I do grant permission for my picture to be taken, which may be used in news releases, agency brochures, posters, or presentations for publicity for Life Learning Center. I understand my photo may also be taken and distributed to the news media to be used in conjunction with a story about Life Leaning Center. I understand I will receive no compensation and hold the agency harmless. I understand that if, at any time, which I voluntarily speak to any media concerning Life Learning Center, and the services that I receive or perform, that it is confidential in nature and I should not disclose personal and/or confidential information. I also understand that I discharge Life Learning Center from liability in the event that I voluntarily or inadvertently disclose confidential information about myself or others.I do NOT grant permission for my picture to be taken or used in news releases, agency brochures, posters, or presentations for publicity for Life Learning Center. I understand this is purely voluntary.
Applicant Signature*

Clear

RELEASE OF INFORMATION:
Name*

First NameLast Name
Birth Date*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email
example@example.com
Acknowledgement of Release of Information:*

I understand that identifying information requested from me will be used by the Life Learning Center staff and associated partners to improve my employment and care opportunities and life transformation. I authorize only information used for this purpose be released to LLC staff and community partners. I understand that I do not have to sign this authorization and that my refusal to sign will not affect my abilities to obtain Life Learning Center (LLC) services. I also understand that I may cancel this Release of Information at any time by submitting a written request to the Life Learning Center Managing Director, except where a disclosure has already been made in reliance on my prior signed authorization. I understand that this Release expires in 12 months from the date executed.
Your Signature*

Clear
Date*

MonthDayYear

RELEASE OF INFORMATION TO PARTNERS:
Acknowledgement of Release of Information to Partners:*

I understand that presenting to Life Learning Center ("LLC") will require LLC staff to communicate with other Treatment providers and judicial entities as appropriate. These team members are participants in the Multidisciplinary Recovery Reentry Team (MRRT) and include, but are not limited to NorthKey Community Care, Journey Recovery Center, SUN Behavioral Health, Transitions Inc., and Ten/Ten Education Program. I understand that: 1. Treatment and/or other confidential information may be discussed during the MRRT meetings. 2. MRRT team members are bound to confidentiality regarding information being shared within the meetings. 3. This authorization is limited in scope to cover only the sharing of information needed for the purpose of continuity of care. 4. I understand that this document will automatically expire 1 year from the date executed. By signing this document, I agree that all my questions about the contents of this document have been answered to my satisfaction.
Signature*

Clear
Date*

MonthDayYear

CRIMINAL CITATION ADDRESS UPDATE:
ATTENTION: The address the court has for YOU is whatever address appeared on your citation(s) you received when you were arrested. If the address on the citation is not correct, or will no longer be correct, please complete this form to update your contact information. Your new address needs to be sent in writing to the Kenton Circuit Court Clerk, in a letter with your case number. Life Learning Center can help facilitate in sending this document on your behalf, please sign and date the bottom giving Life Learning Center permission to send this in your stead or send a hard copy of this document to the address below:

Kenton Circuit Court Clerk John Middleton

230 Madison Ave., 3rd Floor

Covington, KY 41011
Select the option below if you DO NOT need to submit an address change to Kenton Circuit Court Clerk:

N/A- I do not need to submit an address change to Kenton Circuit Court Clerk
Name

First NameLast Name
New Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Citation Number
Probation Officer
Probation Officer's Phone Number
Please enter a valid phone number.
Probation Officer's Email Address
example@example.com
Applicant Signature*

Clear
Date*

MonthDayYear

Should be Empty:

REFERRAL SOURCE:

Life Learning Center Candidate Intake Application

IDENTIFYING INFORMATION:

EMERGENCY CONTACT:

APPLICANT DEMOGRAPHICS:

HOUSEHOLD & FAMILY:

CRIMINAL HISTORY:

HOUSING & TRANSPORTATION:

SUBSTANCE USE & RECOVERY:

HEALTH COVERAGE & ACCESSIBILITY:

PHYSICAL HEALTH:

MENTAL HEALTH:

PUBLIC BENEFITS & EMPLOYMENT:

PRE-PROGRAM SELF-ASSESSMENT:

PHOTO & MEDIA RELEASE:

RELEASE OF INFORMATION:

RELEASE OF INFORMATION TO PARTNERS:

CRIMINAL CITATION ADDRESS UPDATE:

READING COMPREHENSION TEST: