Today's Date
MM
DD
YYYY
Name
*
First Name
Last Name
Email
Age
Date of Birth
*
Social Security Number
*
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
*
(###)
###
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Are you homeless?
Are you married?
If yes, Spouse’s Name:
Do you have children?
If yes list ages:
Are you court ordered to pay child support?
Amount?
Are you behind?
If yes, the amount behind?
Do you have any contacts in this area?
Are you currently employed?
What type of work do you enjoy?
Most recent employer and phone number:
List any previous employers and phone numbers:
Are you currently on probation or parole?
Probation or parole officer name:
Officer Phone
(###)
###
####
Attorney’s Name:
Attorney’s Phone:
(###)
###
####
Attorney’s Email
Have you ever committed/charged with arson?
Have you ever committed/charged with a violent crime?
Have you ever committed/charged with a sexual crime?
Have you ever been involved in any violence?
Please describe:
Drug #1
Age at first use:
Date last used:
Drug #2
Age at first use:
Date last used:
Drug #3
Age at first use:
Date last used:
Drug #4
Age at first use:
Date last used:
Drug #5
Age at first use:
Date last used:
Drug #6
Age at first use:
Date last used:
Have you ever lived in a sober living facility before?
Date last used:
If yes, how long were you there?
How long was the program?
Have you ever participated in a treatment program?
If yes, where? Dates?
List any/all medications:
If accepted into our program, how will you pay for your medications?
Are you under a doctor’s care?
If yes, Doctor’s name and phone number:
Are you suicidal?
Have you ever tried to commit suicide?
If yes, date of last incident?
Describe your mental health:
Have you ever been diagnosed with any Psychiatric or Mental health disorder?
If yes, have you had at least two years of controlled symptoms?
Have you ever been a victim of a violent crime?
If yes, do you currently have a restraining order or ex-parte on abuser?
On a scale of 1 to 10, how serious a problem do you think you have with addiction?
On a scale of 1 to 10, how motivated are you to make a change in your life currently? Please be honest.
What are your life controlling issues?
What is your spiritual background and or view on God?
How do you believe Kingdom Builders Ministry can help you and WHAT are YOU willing to give up to have a life in Christ?
Tell us one thing about you that very few people know:
Date
*
MM
DD
YYYY
Name
*
First Name
Last Name
I affirm that my answers and information provided by me in this application are true and accurate. I understand that if I am accepted, any misinformation and/or dishonest answers may be grounds of denial or dismissal from our program. For with God nothing shall be impossible. Luke 1:37
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