Name
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First Name
Last Name
Email
*
Phone
(###)
###
####
Is it safe to contact you by phone if needed?
Please include address. You do not need to provide an exact address if it makes you uncomfortable.
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Gender
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Birthday
MM
DD
YYYY
Age
Citizenship
*
Primary Language
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Marital Status
Do you have any children?
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If you have any children, how many, age, and do you have custody?
If you have custody of your children, would they need to join you in a program?
Have you previously been involved in a restoration home program?
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Did you complete the program?
Faith Based Program
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Many long term programs are faith based, are you ok with being placed in one of these programs?
Do you have a history of drug or alcohol abuse?
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What is your drug of choice?
If yes, (drug abuse) when was the last time you used?
Have you been in treatment before?
If yes, did you successfully complete?
How many times have you been in substance abuse treatment?
When, where and approximate year.
If accepted into the program, are you willing to have a substance abuse assessment before coming into the program and are you willing to follow the recommendations?
Do you have a history of mental health issues?
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Have you been hospitalized or treated for any mental health issues?
If yes, what are your diagnoses?
Do you struggle with self injury?
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If so, how long ago was the last time?
Do you have any medical conditions that you are currently being treated for by a medical provider?
*
If yes, please expand
Do you have any outstanding legal charges?
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If yes, will you have to report for parole or probation?
Can parole or probation be transferred to our country?
Do you have any upcoming court dates?
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If yes, please expand
Are there any current conditions placed on you by the court?
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Are you currently in what you would consider a safe place?
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If you aren't in a safe place, please explain
Do you identify with having been trafficked?
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If you answered yes to identifying as having been trafficked, please expand further
By sharing your story with us, it allows us to capture a glimpse of your lived experience. Our goal with this question is to allow you the space to share your story one time and for us to be able to share this with our partners in order to help you find the program that you are needing and not have you share your experience repeatedly.
Todays Date
MM
DD
YYYY
If you are asking for placement into a long term program, please share your reasons for doing so
Do you believe that there is anything that may prevent you from finding success in the long term program?
If you were to be accepted into the program, do you have your own means of transportation?
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I certify that all information in this form is accurate and true to the best of my knowledge
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I am voluntarily disclosing this information with Catalyst Ministries in order to receive my requested help
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By submitting this information, I consent to its release on my behalf for the express purpose of seeking services through Catalyst Ministries and their participating network of referral receiving agencies. This information may only be shared with Catalyst Ministries and its trusted service providing partners.
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