New Life Sober Ministries Application
Is a Christian-based, highly structured 4-phased drug and alcohol rehabilitation/prison re-entry program that is a minimum of six months. This program is not easy; there are many rules and regulations and there is strict accountability for one’s actions. It is for those few men who want it and are willing to go to any length to get it. With diligence, self-discipline and a fierce willingness to change, it is possible to complete the program.
Name
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First Name
Last Name
How can we get in touch with you? Please provide phone number or email
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ApplicationDate
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Month
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Day
Year
Date
DOB
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Month
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Day
Year
Date
AIS#
What are you charged with?
Are you a sex Offender?
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Yes
No
If in custody, which jail/prison are you in
If you have an attorney please provide name , phone number and email address
Are you willing to commit 6 months to this program?
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Yes
No
Do you believe that drugs and or alcohol were/are a problem?
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Yes
No
Are you currently on Suboxone?
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Yes
No
What is your drug(s) of choice
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How do you describe your health?
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Fair
Good
Excellent
Do you have any limitations on working?
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Yes
No
If yes, Explain
Are you on any mental health medications?
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Yes
No
Do you receive a check for SSI or disability?
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Yes
No
If yes what is your disability and limitations
Write a short paragraph on why you want to come to our rehab/re-entry program
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