Application

Date (required)

Birth Date (required)

Full Name (required)

Complete Address (required)

Phone (required)

Where are you living at this moment? (required)

Referred by (required)

May we contact them? (required)

Have you ever had a relationship with God? (required)

Are you willing to work towards developing a relationship with God? (required)

Are you currently employed? (required)

If yes, how long have you been there?

Are you willing to cease working in order to be in NSL?

Do you have any children? If yes, how many/ages?(required)

Where are your children/who has custody?

Are you currently in an intimate and committed relationship? (required)

If yes, what is their name?

Will you agree to disconnect from the relationship for 12 to 18 months? (required)

Do you have a cell phone? (required)

Will you agree to turn it in and not have a phone while in NSL? (required)

Are you currently dependent on/or take drugs or alcohol? (required)

Are you willing to go to inpatient treatment? (required)

Do you smoke cigarettes? (required)

If yes are you willing to quit? (required)

If you are incarcerated how long have you been detained?

Do you have charges pending? (required)

If yes, what are the charges?

If yes, what is your probation officer's name?

Probation company's name and phone number?

Have you been convicted or revoked to serve? (required)

If yes, how long is your sentence?

How much time has been built into your sentence?

Where are you currently being housed? (required)

Address of facility? (required)

Do you have any health issues? (required)

If yes, what are your health issues?

We must have a release of information to communicate with your health care and/or mental health providers; will you be willing to sign one? (required)

When was your last physical? (required)

You will be required to obtain a physical prior to admission, please use your local health department. (Must obtain CBC Hep panel, hiv/aides, pregnancy test and physical).

What is the condition of your teeth? (required)

What is the condition of your eyes? (required)

Do you have a mental health diagnosis? (required)

What age were you diagnosed and what is the diagnosis? (required)

Are you pregnant? (required)

There is a $500.00 non-refundable intake fee at the time of entry into Next Step for Life. Monthly fees will be discussed at the time of the interview. Next Step for Life is a drug/alcohol/tobacco-free program. By submitting this application, you are acknowledging this. Our intake coordinator will follow up with you at the earliest convenience.