PM Women's Application

Pierced Ministries & Rehab Services, Inc.

Women's Application
At the very minimum, Pierced Ministries & Rehab Services, Inc. is at least a 6-12 month program. If you are not willing to invest at least 6-12 months into your recovery process, we are not the best fit for you. Please do not proceed with this form, if you are not willing to commit.
Personal Information
Name

First NameMiddle NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Social Security Number
Birthdate

MonthDayYear
Date
Are you currently incarcerated, in detox, or some other type of program?

YesNo
If you answered yes to the question above, what type of program and where is it located?
If you are incarcerated, in detox, or some other type of program, when is your potential release date?
If you are incarcerated, in detox, or some other type of program, what is the contact information that we need to know?
If you are incarcerated, in detox, or some other type of program, do you have a patient code or inmate number?

YesNo
If you answered yes to the question above, what is the patient code or inmate number, so we can follow-up with your application?
Do you have a valid driver's license?

YesNo
Driver's License Number
Marital Status
Have you ever been pregnant?

YesNo
Are you pregnant now?

YesNo
Have you ever had an abortion?

YesNo
Names and Ages of Children
Are you currently involved with DSS concerning your children?

YesNo
If applicable, who has custody of your children?

First NameLast Name
Emergency Contact

First NameLast Name
Emergency Contact's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact's Phone Number
Please enter a valid phone number.
Educational Background

Didn't Graduate High SchoolGEDSome College/Didn't CompleteAssociate's DegreeBachelor's DegreeMaster's Degree
If you did not complete high school, do you have a goal of getting your GED?

YesNo
Legal Status
Have you ever been arrested?

YesNo
If you have been arrested, how many times?
List ALL charges:
Do you currently have pending charges?

YesNo
If you do have a pending charge, what is it?
Do you have any outstanding warrants for arrest?

YesNoUnsure
Are you listed as a Registered Sex Offender?

YesNo
Have you ever been on probation?

YesNo
Are you currently on probation?

YesNo
If you are currently on probation, what is the name of your probation officer?

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County
Probation Officer's Phone Number
Please enter a valid phone number.
Have you ever been in prison?

YesNo
If you have been to prison, when?
If you have been to prison, where?
Are you currently on parole?

YesNo
If you are on parole, what is the name of your parole officer?

First NameLast Name
Parole Officer's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County
Parole Officer's Phone Number
Please enter a valid phone number.
Do you have an attorney?

YesNo
Attorney #1 Name

First NameLast Name
In which county is this attorney representing you?
Attorney #1's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Attorney #1's Phone Number
Please enter a valid phone number.
Attorney #1 Fax Number
Please enter a valid phone number.
Attorney #1's Email
example@example.com
Attorney #2 Name

First NameLast Name
In which county is this attorney representing you?
Attorney #2 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Attorney #2 Phone Number
Please enter a valid phone number.
Attorney #2 Fax Number
Please enter a valid phone number.
Attorney #2 Email
example@example.com
Attorney #3 Name

First NameLast Name
In which county is this attorney representing you?
Attorney #3 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Attorney #3 Phone Number
Please enter a valid phone number.
Attorney #3 Fax Number
Please enter a valid phone number.
Attorney #3 Email
example@example.com
Is there any further legal information that we should be aware of?
Employment Information
Are you currently employed?

YesNo
If yes, list your employer's name, address, and phone number

First NameLast Name
Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please enter a valid phone number.
What other work have you previously done?
Do you enjoy this type of work?

YesNo
If not, what type of work would you rather be doing?
What was your longest period of employment?
What company were you working for at the time?
Why did you leave?
What was your longest period of unemployment?
What did you do during this time?
Have you ever served in any branch of the military?

YesNo
If yes, please answer:

ActiveReserve
What branch of service?
Dates of Service

MonthDayYear
Start Date
MonthDayYear
End Date
Type of Discharge
Were you ever deployed in a combat zone or in a combat support situation?

YesNo
If yes, please explain:
Financial Information
Are you responsible for paying child/spousal support?

YesNo
If yes, how will this be paid while you are in recovery with Pierced Ministries?
Do you receive Disability or Pension?

YesNo
Are you currently receiving SSI?

YesNo
What is your primary source of income?
Do you have someone who can handle your income while you are in Pierced Ministries?

YesNoNot Applicable
If so, who?

First NameLast Name
Medical History
Height
Weight
Check if you have any of the following medical conditions:

DiabetesSeizuresBack/Neck ProblemsAny Sexually-Transmitted DiseaseCancerHeart ProblemsHigh Blood PressureOther
If other, please explain:
List all medications you are currently taking:
Please list any allergies:
Do you have any physical limitations?

YesNo
If yes, please explain:
Do you have a history of depression, manic depression, or Schizophrenia?

YesNo
If yes, are you currently taking medication for these issues?

YesNo
Have you ever been committed, voluntarily or involuntarily, to any mental health facilities?

YesNo
If yes, please list where, when, and the diagnosis you received:
Have you ever tried to commit suicide?

YesNo
If yes, why?
Have you ever self-mutilated?

YesNo
How?
Do you currently, or have you ever had a problem with food or eating?

YesNo
If yes, please explain:
Sexual History
Do you think you were sexually abused growing up?

YesNo
If yes, please explain:
How old were you when you began to be sexually active?
Have you been involved with someone of the same sex?

YesNo
Are you currently in a homosexual relationship?

YesNo
Do you have any unusual sexual preferences?

YesNo
If yes, please explain:
Have you ever been a victim of rape?

YesNo
If yes, how old were you?
Have you ever been a victim of incest?

YesNo
If yes, how old were you?
Have you ever been involved in prostitution?

YesNo
Alcohol & Drug Use
Do you engage in any behavior that you wish you could stop (compulsive), or are you addicted to an activity or substance?

YesNo
Have you ever used:
Tobacco

NeverOccasionallyFrequentlyDrug of Choice
Average Daily Use
Alcohol

NeverOccasionallyFrequentlyDrug of Choice
Average Daily Use
Downers

NeverOccasionallyFrequentlyDrug of Choice
Average Daily Use
Uppers

NeverOccasionallyFrequentlyDrug of Choice
Average Daily Use
Heroin

NeverOccasionallyFrequentlyDrug of Choice
Average Daily Use
Cocaine

NeverOccasionallyFrequentlyDrug of Choice
Average Daily Use
Crack

NeverOccasionallyFrequentlyDrug of Choice
Average Daily Use
LSD (Acid)

NeverOccasionallyFrequentlyDrug of Choice
Average Daily Use
PCP (Angel Dust)

NeverOccasionallyFrequentlyDrug of Choice
Average Daily Use
Opiates

NeverOccasionallyFrequentlyDrug of Choice
Average Daily Use
Marijuana

NeverOccasionallyFrequentlyDrug of Choice
Average Daily Use
Meth

NeverOccasionallyFrequentlyDrug of Choice
Average Daily Use
Valium

NeverOccasionallyFrequentlyDrug of Choice
Average Daily Use
Inhalants

NeverOccasionallyFrequentlyDrug of Choice
Average Daily Use
Needle Use

NeverOccasionallyFrequentlyDrug of Choice
Average Daily Use
Suboxone/Methodone

NeverOccasionallyFrequentlyDrug of Choice
Average Daily Use
Please list any other substances that you are struggling with:
Rehab History
Have you ever been to any rehab programs before?

YesNo
If yes, list all programs and dates starting with the most recent:
How many of these programs did you complete?
Why do you feel the other programs didn't work for you?
Do you accept that your first 60 days in Pierced Ministries and Rehab is a probationary period?

YesNo
Do you admit that you have an addiction problem, and are you committed to allowing God to move you into recovery?

YesNo
Spiritual Information
What is your relationship with Christ at this time?
Where would you like to take your relationship with Christ?
Name 3 short-term goals that you would like to accomplish:
Name 3 long-term goals that you have for yourself:
Essay
In your own words, tell us why you desire to enter Pierced Ministries and the circumstances that led you to this point.
Please note: Pierced Ministries is not a medical facility. You must take care of all medical, dental, or mental health issues prior to entry.
I certify that the answers I have given are true and complete, to the best of my knowledge. Providing false information will be grounds for dismissal. I agree that I will complete this recovery program. I also agree that if I leave prior to completion, I may not be readmitted. I agree to participate in all required functions of Pierced Ministries, including but not limited to: daily Bible studies and classes, church services, work programs on and off Pierced Ministries' properties, counseling sessions, and other requirements.
Signature

Clear
Date

MonthDayYear
Date
Consent to Share Information Form

Pierced Ministries & Rehab Services, Inc. has a joint agreement with First Contact Addiction Ministry to help find placement for men and women seeking placement into a long-term, recovery program for substance abuse. First Contact provides free support services for addiction and recovery. A placement specialist from First Contact has agreed to help us find placement for our applicants, should the need arise, that are willing to seek long-term treatment with another facility.
The purpose of this consent form is to give Pierced Ministries & Rehab Services, Inc. permission to share your application information with First Contact Addiction Ministry. I understand that any information shared between Pierced Ministries & Rehab Services, Inc. and First Contact Addiction Ministry is for the sole purpose of helping me find a recovery program faster. I understand that giving consent is completely voluntary. If I choose not to consent, it could result in waiting for a bed until one becomes available, which could be up to a few months.
I, blanks , give permission for Pierced Ministries & Rehab Services, Inc. to share my information with First Contact Addiction Ministry.
Applicant's Name

First NameLast Name
Date

MonthDayYear
Date
Signature

Clear
Should be Empty:

Pierced Ministries & Rehab Services, Inc.

At the very minimum, Pierced Ministries & Rehab Services, Inc. is at least a 6-12 month program. If you are not willing to invest at least 6-12 months into your recovery process, we are not the best fit for you. Please do not proceed with this form, if you are not willing to commit.

Personal Information

Legal Status

Employment Information

Financial Information

Medical History

Sexual History

Alcohol & Drug Use

Rehab History

Spiritual Information

Essay

Consent to Share Information Form