Alive at Last Participation Application

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How did you hear about Alive at Last?
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Participation Preferences
Access to our private online community and resources
Attend a small group in person while in shelter
Attend a small group online
Be matched with an Alive at Last Mentor
Attend Alive at Last Conferences and/or Retreats
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Full Name* This field is required.
First Name
Last Name
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Email* This field is required.
example@example.com
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Phone Number* This field is required.
Area Code
Phone Number
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Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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Date of Birth* This field is required.
Date
Year
Month
Day
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Ethnicity
Black/African American
Hispanic/Latin
Asian/South Asian
White/Caucasion
Other
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Do you have any children and grandchildren?Please share how many of each and their ages.
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Emotional
emotional healing
making peace with the past
be encouraged
discover indentity: gifts, strengths, preferences
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Social
finding new friends or support circle
learning to trust
handling difficult relationships
experience authentic friendship
participate in fun activities
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Spiritual
forgiving myself
forgiving others
learning the basics of faith
have prayer support
grow in my faith
discover God-given purpose
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Work
how to act in the workplace
managing work relationships
how to keep a job
know my aptitudes (what I do or like to do)
create a personalized career path
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How would you describe your current physical health?(Excellent/Good/Fair/Poor)
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Are you receiving any kind of emotional or mental health support?Counseling, medication, etc.
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Are you currently feeling safe?Physically, Relationally, Emotionally, Mentally, Spiritually
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Have you ever experienced sexual trauma, abuse, exploitation, or trafficking?
YESNO
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If you answered yes to the last question, at what age did this start?
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Please check all that apply.
Sexual Abuse
Molestation
Sexual Assault
Forced to perform sexual acts
Sexual contact with family members
Manipulated to perform sexual acts
Stripping
Escorting
Prostitution
Had a pimp
Rape
Used sexuality in exchange for drugs, money, a place to stay, items of value
Trafficking (force, fraud, or coercion involved in commercial sex act)
Other
None of the above apply
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The effects of abuse can lead to other struggles. Are you struggling with any behaviors with which you may need some extra support:
recreational drug or alcohol use
eating disorder
workaholism
sexual addiction
internet addiction
spending addiction
codependency
other:
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Are there any other struggles are you currently facing that you would like help with?
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Small
Ok
Ok
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Are you currently receiving help for any of this struggles?Yes/No If yes, please specify.
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Ok
Ok
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Have you had any involvement with the justice system? Such as Rise Court or Star Court? Are you currently on probation or parole? Please specify.
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Ok
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Do you identify as a Christian?(Yes/No/Not Sure/Prefer not to say)
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If not, what is your belief system or faith background?
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How would you describe your spiritual life?
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Are you open to discussing faith or spiritual topics while participating in our program?Yes/No/Maybe
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What is the highest level of education you have?
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Are you currently working through any educational programs?If yes, please share more about what you are working toward.
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Do you have any specific training, certificates, or special skills?If yes, please share
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Are you currently employed?If yes, please share what type of work you are doing. If no, please share your work situation.
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What are your hopes for your future - for family, education, work, spiritual life, etc?
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Ok
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Are you interested in one to one mentorship through Alive at Last?Yes/No/Maybe
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What would you like to gain from having a mentor?Examples: encouragement, accountability, life skills, parenting tips, prayer support, spiritual guidance
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Do you have a preference for a mentor? (age/life stage/ethnicity/background)Please specify
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What areas of life do you most want support in?
Emotional
Faith/spiritual
Parenting
Education
Job/Career
Skills Training
Finances
Tapping into Resources
Friendship
Other
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What are your biggest life goals right now?
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Please check the boxes below that you agree with
I declare I have answered these questions truthfully and to the best of my ability.
I am committed to making the most of the opportunity to be matched with an Alive at Last mentor.
I am ready to get started as soon as possible with a mentor.
I am not ready for mentorship at this time.
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