Fresh Wind Recovery Women's Ministry
Pre-Application Form
Please note, the following survey collects sensitive data and PII (Personally Identifiable Information).
I have read the above and consent to Fresh Wind Ministries collecting sensitive and PII data about me.
Provide Your Full Name (i.e. first, middle initial and last name)
*
First Name
Middle Int.
Last Name
Preferred Name:
What Do You prefer to be called?
Do You Identify As Male?
Yes (Fresh Wind has a program for men also)
No
What is your current telephone/contact number?
*
If you are currently residing within a facility (jail, prison, hospital, detox unit), please indicate a contact person/case manager that we may contact. If you are incarcerated, what is your release date, court date, or sentencing date?
Emergency Contact Number/s
For a family member, case manager, community supervision officer, etc.
Were you referred to treatment at Fresh Wind?
Yes
No
Who or what agency referred you to Fresh Wind?
Please Select
Community Supervision (Probation or Parole)
Georgia Department of Family & Children Services (DFCS)
Athens/Clarke Judicial Circuit Drug Court
Serenity Behavioral Health Systems
Georgia Regents Health System (GRU)
Georgia Behavioral Health Link
Other
Email
*
example@example.com
Date of Birth
*
 -
Month
 -
Day
Year
Date
Are you currently incarcerated
*
Yes
No
If so, what is the name of the institution
If no, you can skip this quesiton
Why are you seeking treatment and/or housing at Fresh Wind? What are the circumstances that lead to your referral?
Ex: "I am an unsheltered resident" or "I have been sentenced to treatment" may be appropriate
Are you or a member of your household subject to a lifetime sex offender registration requirement in Georgia or in other states where you are known to have resided?
Yes
No
Do you have medical insurance?
Yes
Noa
What company do you have medical insurance with? What is your policy and group number? If you do not have insurance, type N/A for not applicable.
If you do not have insurance, type N/A for not applicable.
Have you ever served in the military?
Yes
No
Has an immediate family member (mother, father, son, daughter, brother, sister) served in the military?
Yes
No
How Do You Identify?
Please Select
Female
Male
Transgender
Gender Varient/Non-Conforming
How Do You Identify? (Sexual Orientation)
What is your current living situation?
Homeless
Staying With Friends
I have an address:
If you have a permanent address please list it here:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Who Were You Living/Residing With?
Spouse
Domestic Partner
Friend
Parent
Lacked Permanent Housing
Other
Are You:
*
Single
Married
Divorced
Domestic Partner
Separated
Widowed
Race?
Caucasian
African American
Latino
Asian
Other
Are You Pregnant?
*
YES
NO
Do You Have Children?
*
YES
NO
Please list Gender and Age of Each Child
Do you have an active Child Protective Services case with the Georgia Department of Family and Children Services?
*
YES
NO
If Yes list the name and contact number of your DFCS case worker/manager
Do You Have Custody of Your Children?
*
YES
NO
What Are Your Child Care Plans?
Family member has temporary custody
Child is no longer a minor
Foster Care
Other
Are You Seeking Reunification With Your Children?
Yes
No
Not Applicable
Are You Currently Employed?
Yes
No
If Yes, Then Where?
*
Do You Have Any Form of Income? (i.e. Social Security Income, Temporary Assistance for Needy Families (TANF), Child Support, etc.)
Yes
No
Please Select Your Source Of Income From the Following:
Temporary Assistance for Needy Families (TANF)
Supplemental Nutrition Assistance Program (SNAP) - Food Stamps
Medicaid
Medicare
Social Security Income (SSI)
Social Security Disability Income (SSDI)
Unemployment Income
Child Support
Other
Please identify the amount of income. If you selected 'Other,' please identify the source of income
35. What was the first age you used alcohol or other drugs?
Under 13
13-15 years old
16-18 years old
18-20 years old
Over 21 years old
What drug(s) do you use?
Alcohol
Methamphetamine
Heroin
Prescription Medication/Pills
Marijuana
Cocaine
Kratom
Other
What method(s) have you used to take your drug(s) of choice?
Drinking
Smoking (pipe, etc.)
Swallow (as pill)
Snort
Injection/Shoot Up (Intravenous Use - IV)
Inhale/Huff
Oral Ingestion (except swallowing)
What was your last date of use and how much?
Do you require detoxification/hospitalization?
Yes
No
Have You Been In Treatment Before?
Yes
No
How many times have you been in treatment?
When and Where Did You Receive Treatment?
Did you ever leave treatment against medical advice (AMA)?
Yes
No
Do you currently have any medical conditions or problems?
Yes
No
List Current Medications You Are Using
*
Mark N/A if "Not Applicable"
Are You Curently Prescribed Any of the Following Medications?
Suboxone
Methadone
Subutex
Buprenorphine
Naltrexone
Vivitrol
None of the Above
Who is your current physician/doctor? If you do not currently have or are seeing a doctor, please list N/A.
*
List All Allergies You May Have, Including Food, Bugs, etc
*
Are You Currently Incarcerated?
Yes
No
Do You Need Medical Attention?
Yes
No
List Any Long Term Medical Conditions (Diabetes, High Blood Pressure, Epilepsy, others)
*
Mark N/A if "Not Applicable"
Is There a History of Substance Abuse in Your Family?
*
YES
NO
Do you have any mental and/or physical disabilities?
Yes
No
If Yes, Please Specify:
Do you currently have any pending or past legal problems?
Yes
No
Please describe the charge, date, and sentence. (i.e. arrested in June 2015 for drug possession in Columbia County, currently participating in drug court services, etc.)
Are you currently under community supervision, i.e. probation or parole in any county, state, or with a federal office?
Yes
No
Please list the contact information for your community supervision officer (name, phone number, address, etc.)
Does your community supervision officer know that you are seeking treatment at Fresh Wind?
Yes
No
How Often Are You Required To Report for Community Supervision?
Enter N/A if not applicable
For compliance and to protect your privacy please expect a phone call from Fresh Wind to share your social security number. Please note: an application cannot be processed without a social security number.
I Understand
I Do Not Understand
Signature
I hereby declare that all the information I have given in this application (survey) is true. I understand that any false information will be grounds for non-admission to or dismissal from the Fresh Wind Recovery program. I also understand that submitting this application does NOT guarantee entrance into the Fresh Wind residential program.
I Agree
I Do Not Agree
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