• Residential Program Application

  • “Yet even now,” declares the Lord, “return to me with all your heart, with fasting, with weeping, and with mourning; and rend your hearts and not your garments.” Return to the Lord your God, for he is gracious and merciful, slow to anger, and abounding in steadfast love; and he relents over disaster. Joel 2:12-13

  • Thank you for your interest in the Pure Life Ministries Residential Program. 

    I realize that it may require a tremendous sacrifice for you to come to our program. However, I assure you that what God does for men here, if they have an open heart and a genuine desire to change, will last for the rest of their lives—and on into eternity!

    Please take your time to carefully answer the following questions. This is a lengthy application and it will take some time to complete. Your progress can be saved at any time by scrolling down to the bottom of the page and clicking "Save and Return."

    If you have any questions concerning the program or the application process, please contact our Director of Intake at intake@purelifeministries.org or by calling 859.824.2137.

    In Christ,

    Luke Imperato

    Luke Imperato

    Director of Counseling

  • Personal Information

  • Reference

  • As part of your application, we require a reference form to be completed by someone other than an immediate family member (preferably a pastor or an elder of your church).

    Please enter the name and email address of the person you would like to be your reference. After you submit your application, they will be sent an email with a link to fill out the reference form. If your reference does not have an email address, please have them visit our application center at https://www.purelifeministries.org/application-center to fill out the online form.

  • Family Information

  • Are you currently living together?
  • Is your spouse willing to participate in counseling?
  • Do You Have Children?*

  • Educational Information

  • Military Service*

  • Employment Information

  • Spiritual Information

  • Does he know about your problem?*
  • Are you saved?*
  • Have you been baptized?*
  • How often do you read the Bible?*
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  • Physical & Emotional Health Information

  • Rate your health:*
  • Do you have any allergies to food, medications, etc.?*
  • Have you been admitted to the hospital for any reason within the past year?*
  • Have you visited the Emergency Room for any reason within the past year?*
  • Are you able to work in the United States?*
  • Do you have physical limitations that might prevent you from holding a full-time job (e.g., standing, sitting, and/or lifting up to 50lbs.)?
  • Do you have any sleep issues or require use of a CPAP machine?*
  • Are you currently prescribed any medication(s)?*

  • * Fitness-related or dietary supplements and sleep-aids are expressly forbidden; only vitamins/minerals for specific health needs are permissible. If you require any medications, vitamins, supplements, etc. regardless of whether they are prescription or over the counter, they must be listed under current medications.

  • Do you agree that you will NOT discontinue or alter the dosage of any prescribed medication during your program without permission and oversight from a licensed physician?*
  • Have you ever had any psychotherapy or other mental health treatment?*
  • Have you ever received a mental health diagnosis?*
  • Are you on medication for mental health issues?*

  • Please ensure all medications are listed under current medications above.

  • Has there been any change in your medications over the past 6 months?*

  • Addictive & Behavioral Information

  • Do you smoke cigarettes or use tobacco products?*
  • In the past 12 months, have you used anything to “get high” (like illegal drugs, prescription or over the counter medications, and things that you snuff, huff, or vape)?*
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  • Legal Information

  • Have you ever been arrested or convicted of any crime?*
  • Are you currently involved in any pending legal proceedings?*

  • Financial Information

  • Do you have any debts or monthly payments at this present time?*
  • The current weekly Program Fee is $250. Are you willing to pay your weekly program fees first before all other bills or obligations?*
  • After your acceptance into the Program has been confirmed, a $1,750 Induction Fee is due. Are you able to pay your Induction Fee?*

  • Other Residential Program Information

  • Have you read the book At the Altar of Sexual Idolatry?*
  • Have you watched the “20 Truths Series” online or through our mobile phone app?*
  • Have you participated in our Overcomers At-Home Program?*
  • Pure Life Ministries uses the Bible as the authority for all counsel and believes that it is the infallible Word of God. At times, the staff of PLM will be confronting you about issues of sin in your life. Do you agree that this needs to happen?*
  • Have you prayerfully thought about the 9-month commitment to the Residential Program and are you sure you are willing to commit yourself for that length of time?*
  • What date will you be ready to start the program?*
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  • Please make sure all questions have been answered before clicking continue.

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