Setting Captives Free Intensive Intake and Commitment Form
Please complete this intake inquiry and agree to the Rules of Conduct and Commitment for participation in the intensive program.
Email address
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Date
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Month
-
Day
Year
Date
Name
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First Name
Last Name
Cell Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Age
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Marital Status
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Single
Married
Divorced
Widowed
Separated
Do you have children?
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Yes
No
If yes, how many children?
If yes, what are their ages? (Please list separated by commas)
Salvation Status (e.g., Saved, Seeking)
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Saved
Seeking
Unsure
If saved, how long?
Are you sober now?
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Yes
No
If yes, how long have you been sober?
How many times have you been to treatment (rehab, intensive program, etc.)?
What drugs have you used? (Please list all substances)
How old were you when you started using drugs?
Do you have any serious medical issues we should be aware of?
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Yes
No
What are your current ongoing physical health issues?
Medical Information: Current medications
What are the medications for?
What are your current mental/emotional concerns? (e.g., anxiety, depression, trauma)
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What situation brought you here?
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Do you have a place to go after you leave this intensive?
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Yes
No
In progress of securing
Do you currently have a job?
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Yes
No
If yes, what is your job/occupation?
What is your relationship like with your family of origin?
What is important for us to know about what has happened to you?
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What do you most need to get out of this intensive?
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Do you read/have read the Bible?
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Yes
No
If yes, how much do you read/study the Bible?
Daily
Weekly
Occasionally
Rarely
Do you currently have a support group (e.g., AA, NA, Celebrate Recovery, church group)?
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Yes
No
Rules of Conduct and Commitment
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I understand and agree to respect all Salvation Army Property here at the Northwood’s Camp.
I understand and agree to no use of drugs, alcohol, and illegal substances during the duration of this Intensive.
I understand and agree there will be no fraternizing with the members of the opposite sex, no meeting in secret, and no making plans to meet through other people.
I understand and agree there will be no leaving the buildings at night, and no leaving the building after 9 at night, except at designated smoke breaks.
I understand and agree to no smoking except outside the building in designated smoking areas at break time, and will put all cigarette butts in the designated containers.
I understand and agree there will be no lying, no running away, and no trying to get staff to give me a ride somewhere.
I understand and agree I will be required to be in class and participate fully in the scheduled activities and teachings.
I understand and agree I will be assigned to a team and be expected to participate in my team.
I understand and agree that I will ask for help when needed.
I understand and agree that lights out will be at 11:00 p.m.
I understand that if I break these rules the consequences will be 1) confess to my peers, 2) prayer for deliverance, and 3) meet with one of our staff for prayer counseling.
Hold Harmless and Indemnification Agreement Acknowledgment
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In consideration of the privilege of using The Salvation Army’s property at the Northwood’s Camp in Finlayson, MN, and participating in this Setting Captives Free Intensive, I agree to hold harmless all staff, speakers, including Life Recovery, Lost Sheep Ministries MN, RiverCity Outreach, and members of Salvation Army staff who are hosting us. I agree that I will not and cannot sue anyone for their good faith efforts to help me walk in the freedom Jesus died to give me.
Signature
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