CCRM Men's Restoration Program

Men's Restoration Program

Cleveland County Rescue Mission
Date of Application *

Month Day Year
Date
Name *

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

Month Day Year
Date
Phone Number
Please enter a valid phone number.
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
Are you currently on parole, probation, under bond, or ordered by the court to seek treatment? *

Yes No
If answered "Yes," for how long & for what?
Parole/Probation Officer Name

First Name Last Name
Parole Officer Address

Street Address

Street Address Line 2 (Optional)

City State / Province

Postal / Zip Code
Parole Officer Phone Number
Please enter a valid phone number.
EMERGENCY CONTACT INFO
Emergency Contact Name

First Name Last Name
Emergency Contact Phone Number
Please enter a valid phone number.
Emergency Contact

Street Address

Street Address Line 2 (Optional)

City State / 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
Select the degree of stress/urgency for applicable areas:

Depression Anxiety/Fear Alcoholism Grief/Loss Workholism Relationships Abandonment Chronic Illness Lonliness Insomnia Eating Disorder Career Decision Mood Swings Adultery Sexual Identity Problems Compulsive Behaviors Physical Abuse Emotional Abuse Occult Oppression Anger/Frustration Loss of Hope Marital Problems Drug Addiction Sexual Abuse Low Self Esteem Financial Crisis Rejection Suicidal Thoughts Other 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.
Have you had any major surgeries, illnesses, or accidents?

Yes No
If yes, please describe here.
MEDICAL INFORMATION
Doctor's Name *

First Name Last Name
Psychiatrist/Psychologist Name

First Name Last Name
Diagnosis
Are you taking any medications? *

Yes No
If yes, list medications here.
Who is prescribing?
Describe your physical health *
Please check all that apply:

Diagnosed for PTSD Prescribed for PTSD Diagnosed Anxiety Prescribed for Anxiety Diagnosed Depression Prescribed for Depression Diagnosed Bipolar Prescribed for Bipolar Diagnosed Schizophrenia Prescribed for Schizophrenia None of the above
Have you taken medication for emotional stress?

Yes No
Have you ever been hospitalized for emotional or mental illness, or substance abuse?

Yes No
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