John 3:17 Ministry Application
Name
*
First Name
Last Name
Age
*
Age
Today's Date
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-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Date
Social Security Number
*
If you have a Probation or Parole Officer- Name, Phone, FAX
*
What are your life controlling issue(s)?
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How do you believe John 3:17 can help you and what are you willing to do?
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Have you been diagnosed with any psychiatric or mental disorders?
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If so, what was the diagnosis and when?
Describe your mental health.
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Are you currently taking medication prescribed by a doctor? If yes, please list medications, diagnosis, and how long you have been taking each medication?
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If you are accepted into our program, how will you pay for your medications?
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Do you have health insurance? If so, what is your carrier?
*
Do you have any allergies?
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Do you have dental issues? If so, please explain.
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Do you have any physical disabilities that would prevent you from daily exercise or physical work?
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Can you walk 2 miles a day?
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Have you been involved in any violence? Please describe.
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Are you legally married? If so, name of spouse.
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Have you ever struggled with homosexuality?
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Please give information about pregnancy or children.
*
What is your spiritual background and/or view of God?
*
Are you homeless at this time?
*
Signature
Submit
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