Your Name
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First Name
Last Name
Your Email
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example@example.com
Name of Applicant
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First Name
Last Name
Your relationship with applicant (pastor, counselor, friend, etc.)
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How long have you known the applicant?
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How would you describe your present relationship with the applicant (good, strained, don't know him that well, etc.)?
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Does the applicant claim to know Jesus Christ as his personal Lord and Savior?
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In your opinion, what are the applicant's motives for coming to this program?
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Is it the applicant's desire to come to our program, or is it someone else's?
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Has the applicant come to you recently for spiritual counsel? If so, what were the results (followed counsel, ignored advice given, became defensive, etc.)?
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Does the applicant have problems submitting to corrective guidance from others? Please explain.
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What are the biggest problems you anticipate the applicant will have while in our program?
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What is the level of commitment (if any) to the church he is involved in?
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Would you consider the person responsible and mature regarding his personal finances?
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This program utilizes biblical homework as a significant aspect of the counseling process. Does the applicant have any reading, comprehension, or academic difficulties we should be aware of?
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What would be your reaction if, after several months, you heard that the applicant had left our program and returned to his old lifestyle?
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Shocked
Rather surprised
Slightly surprised
Not surprised
Expected it
What is the applicant's most serious weak points (emotionally and spiritually)?
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What are his strongest points?
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Are you aware of other problems concerning the applicant that we should know about?
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Do you recommend that we accept the applicant into our program?
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Yes
No
Please explain.
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Please evaluate the applicant to the best of your ability by circling the correct number: 1=never true 2=seldom true 3=sometimes true 4=often true 5=always true
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Rows
1 (Never)
2
3
4
5 (Always)
Teachable
Demanding
Stable
Growing spiritually
Moody
Responsible
Submissive
Humility
Open/real
Legalistic
Cooperative
Troublesome
How did you first hear about Pure Life Ministries?
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Web Search Engine
Referral by Pastor or Counselor
Book/PLM Resource
Pure Life Ministries Podcast
Social Media Post/Ad
Referral by Family or Friend
PLM Annual Conference
TV or Radio Interview
Web Link/Ad
Unchained Magazine
Call to Purity Weekend or Other Event
Other
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I hereby declare that, to the best of my knowledge and understanding, the information I have provided above is correct and/or represents my true opinion of each question asked.
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It is important for you to know that by submitting your application online, Pure Life Ministries uses third-party applications that are secure and GDPR compliant to transfer and store your information for your enrollment in our Residential Counseling program.
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