CCRM Men's Restoration Program

Men's Restoration Program

Cleveland County Rescue Mission
Date of Application*

MonthDayYear
Date
Name*

First NameLast Name
Age*
Race*
Sex*
Date of Birth*

MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Highest Education Level Completed
Child's Name - Age - Sex - Relationship - In Home? Y/N
Please separate child's information with commas ( , )
Who Were You Referred By?
JOB INFORMATION
Desired Employment?
List any job skills here.
LEGAL STATUS
YesNo
If answered "Yes," for how long & for what?
Parole/Probation Officer Name

First NameLast Name
Parole Officer Address

Street Address

Street Address Line 2 (Optional)

CityState / Province

Postal / Zip Code
Parole Officer Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
EMERGENCY CONTACT INFO
Emergency Contact Name

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact

Street Address

Street Address Line 2 (Optional)

CityState / Province

Postal / Zip Code
SPIRITUAL HISTORY

Because our Ministry is based on Biblical values and principles, the following information will be helpful in our assessment.
List your religious background in childhood here (briefly describe).
Church Affiliation
DepressionAnxiety/FearAlcoholismGrief/LossWorkholismRelationshipsAbandonmentChronic IllnessLonlinessInsomniaEating DisorderCareer DecisionMood SwingsAdulterySexual Identity ProblemsCompulsive BehaviorsPhysical AbuseEmotional AbuseOccult OppressionAnger/FrustrationLoss of HopeMarital ProblemsDrug AddictionSexual AbuseLow Self EsteemFinancial CrisisRejectionSuicidal ThoughtsOther Crisis Issues
If "Other Crisis Issues," list here:
Explain/List any suicidal thoughts, plans, attempts, etc. here.
Explain/List any homicidal thoughts, plans, attempts, etc. here.
Explain/List any desires to inflict pain to self or others here.
Explain/List any fears of life or personal safety here.
Explain/List any instances where you have been too depressed to care for self or family here.
YesNo
If yes, please describe here.
MEDICAL INFORMATION
Doctor's Name*

First NameLast Name
Psychiatrist/Psychologist Name

First NameLast Name
Diagnosis
YesNo
If yes, list medications here.
Who is prescribing?
Describe your physical health*
Diagnosed for PTSDPrescribed for PTSDDiagnosed AnxietyPrescribed for AnxietyDiagnosed DepressionPrescribed for DepressionDiagnosed BipolarPrescribed for BipolarDiagnosed SchizophreniaPrescribed for SchizophreniaNone of the above
YesNo
YesNo
When was your most recent Physical?
Physician who conducted Physical:
Any significant findings from your most recent Physical?
Any recommended treatment for your most recent Physical?
Do you have any history of convulsions, seizures or blackouts?
Do you have any allergies?
Any other medical problems?
Should be Empty:

Men's Restoration Program

JOB INFORMATION

LEGAL STATUS

EMERGENCY CONTACT INFO

SPIRITUAL HISTORY

MEDICAL INFORMATION