Renew Intake Application
Online Applications are Confidential
General Information
Name
*
First Name
Last Name
Address (where are you staying)
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Best way to contact you
*
Phone or Email
How did you hear about the Mission?
*
Program Information
The program is 1 year long. The first 6 months you are unable to work and will be in classes. Are you able do this?
*
Yes
No
Uncertain
The program focuses on not being controlled by substances (i.e., alcohol, illegal substances, recreational use of pharmaceuticals, THC, nicotine, etc.) Are you willing to work towards a healthy substances free life?
*
Yes
No
Uncertain
Electronic usage is limited during the first 4 months of the program. You will not have a personal cell phone until after approximately 4 months. Can you comply with this rule?
*
Yes
No
Uncertain
There are to be no romantic relationships while in the year long program unless you are legally married. Can you adhere to this rule?
*
Yes
No
Uncertain
The program includes work therapy and vocational training components. Are you willing and able to learn and share in responsibilities in chores and work therapy?
*
Yes
No
Uncertain
The program addresses emotions, relationships, and trauma. Are you willing to submit to the recovery process in a Christ-centered/biblical program?
*
Yes
No
Uncertain
Emergency Contact
Name
*
First Name
Last Name
Relationship
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Alternate Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Marriage and Family Information
Martial Status
*
Single
Married
Separated
Divorced
Widowed
Name of spouse
*
Type name or N/A if you are not married
Do you keep in contact with your spouse and/or children?
*
Yes
No
Not applicable
Children's Information
Rows
Name of child
Age
Sex
Last contact
Pay child support
1
Female
Male
Yes
No
Should Be
2
Female
Male
Yes
No
Should Be
3
Female
Male
Yes
No
Should Be
4
Female
Male
Yes
No
Should Be
5
Female
Male
Yes
No
Should Be
6
Female
Male
Yes
No
Should Be
Employment & Financial
Highest level of education?
*
Less than high school diploma
High school diploma/GED
College
When were you last employed?
*
Where were you last employed?
*
Do you presently have an income?
*
Yes
No
If so, how much?
*
From what source?
*
Type source of income or N/A
Do you receive social security?
*
Yes
No
Do you pay child support?
*
Yes
No
Should be
Does not apply
Legal Information
Are you a registered sex offender?
*
Yes
No
Are you presently on probation or pre-parole or parole?
*
Yes
No
If so, what is your agent's name?
Are you presently on DA Supervision?
*
Yes
No
If so, what county?
Do you know of any warrants out on you?
*
Yes
No
Uncertain
Counties of current warrants
List all convictions or pending legal action
*
Do you know of any fines that you owe?
*
Yes
No
Uncertain
If so, what counties?
Medical & Mental Health
Date of last medical examination
*
Your physician
*
Rate your health
*
Very Good
Good
Average
Declining
Poor
Current medical conditions
*
Previous medical conditions
*
Date of last mental health appointment
*
Location of last mental health appointment
*
Mental health issues/diagnoses
*
Have you recently thought of taking your own life?
*
Yes
No
Have you attempted suicide in the past 6 months?
*
Yes
No
Have you ever attempted suicide?
*
Yes
No
Current medications
*
Medical allergies
*
TB test date
*
TB test location
*
Substance Use
Drug(s) of choice
*
When was the last time you used any drug, substance or pill (other than how prescribed)?
*
Have you ever been in treatment for drug or alcohol abuse or addiction?
*
Yes
No
If yes, when and where?
Substance Use History
*
Rows
Frequency
Method of Use
First Used
Last Used
Nicotine
Daily
Weekly
Monthly
Rarely
Never
Smoked
Snorted
Ingested
Drank
Shot up
Alcohol
Daily
Weekly
Monthly
Rarely
Never
Smoked
Snorted
Ingested
Drank
Shot up
Marijuana
Daily
Weekly
Monthly
Rarely
Never
Smoked
Snorted
Ingested
Drank
Shot up
Ecstasy/MDMA
Daily
Weekly
Monthly
Rarely
Never
Smoked
Snorted
Ingested
Drank
Shot up
Hallucinogens (LSD, shrooms, PCP, etc.)
Daily
Weekly
Monthly
Rarely
Never
Smoked
Snorted
Ingested
Drank
Shot up
Inhalants
Daily
Weekly
Monthly
Rarely
Never
Smoked
Snorted
Ingested
Drank
Shot up
Opiates (opium, heroin, morphine, oxy, fentanyl, etc.)
Daily
Weekly
Monthly
Rarely
Never
Smoked
Snorted
Ingested
Drank
Shot up
Sedatives (barbiturates, downers, etc.)
Daily
Weekly
Monthly
Rarely
Never
Smoked
Snorted
Ingested
Drank
Shot up
Stimulants (cocaine, meth, Ritalin, etc.)
Daily
Weekly
Monthly
Rarely
Never
Smoked
Snorted
Ingested
Drank
Shot up
Abuse of Prescription Drugs
Daily
Weekly
Monthly
Rarely
Never
Smoked
Snorted
Ingested
Drank
Shot up
Kratom
Daily
Weekly
Monthly
Rarely
Never
Smoked
Snorted
Ingested
Drank
Shot up
Other
Daily
Weekly
Monthly
Rarely
Never
Smoked
Snorted
Ingested
Drank
Shot up
How serious do you think your drug problems are?
*
Not at all
Slightly
Moderately
Considerably
Extremely
How important is it for you to get drug treatment now?
*
Not at all
Slightly
Moderately
Considerably
Extremely
Outlook on Life
Personal goals:
*
What would you like to receive from John 3:16 Mission?
*
Who do you know that is staying at the Mission?
*
All information contained in this biographical information form is true and accurate.
*
Submit
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