Please enable JavaScript in your browser to complete this form.Today's Date: *Full Name *FirstMiddleLastBirth Date: *AddressCity/StateYour city and state (ex: Cookeville, TN)Zip Code *Phone Number *Please enter a valid phone number where our intake coordinators can reach you. Where are you living at this moment? *If you are filling this out for an individual who is incarcerated, please specify that they are incarcerated along with the name of the facility and the city and state in which it is located. Referred by: In order to help us reach more individuals,, if you have been referred by an individual or organization, please specify in this box. May we contact them?YesNoMay we contact the above individual or organization who referred you to us on your behalf?Have you ever had a relationship with God? *YesNoPrefer not to sayAre you willing to work towards developing a relationship with God? *YesNoAre you currently employed? *YesNoIf yes, how long have you been there?Are you willing to cease working in order to be in the NSL program? *YesNoDo you have any children? *YesNoIf you answered yes to the above, how many?What are their ages?Please separate with commas. (example 4 Kids ages: 1, 3, 8, 10 would be 1,3,8,10)Where are your children/who has custody?If your children are not with you please specify who has custody either an individual or an organization such as Department of Childrens Services. Are you currently in an intimate/committed relationship? *YesNoIf yes, what is their name?FirstLastWill you agree to disconnect from any romantic/intimate relationships (outside of marriage) for 12 to 18 months? *YesNoDo you have a cell phone? *YesNoWill you agree to turn it in and not to have a phone while in NSL? *YesNoResidents of the Next Step for Life program are not allowed to have cell phones. Do you currently use or are you dependent on drugs or alcohol? *YesNoAre you willing to go to inpatient treatment? *YesNoDo you smoke cigarettes? *YesNoAre you willing to quit smoking? *YesNoIf incarcerated, how long have you been detained?Do you have charges pending? *YesNoIf yes, what are the charges? Do you have any upcoming court dates?Please be specific. If you have court dates, please mention when and where as well as the city and state. Are you on probation/parole? *YesNoIf yes, what is your probation officer's name?FirstLastProbation company's name and phone number:Have you been convicted or revoked to serve?YesNoIf yes, how long is your sentence?Please be specific. How much time has been built into your sentence?Where are you currently being housed?If the person named in this application is in a facility, please provide the facility name here. Address of facilityCity/State of the facilityDo you have any health issues? *YesNoIf yes, please specify: Are you currently prescribed to any medications (this includes psych meds as well)? *YesNoIf you answered "yes" to the above, please specify the name of the medication, the dosage, how frequently per day you are to take it, the name of the prescribing physician, and the diagnosis.We must have a release of information (ROI) to communicate with your health care and/or mental health providers; are you willing to sign one? *YesNoWhen was your last physical *If you have never had one, please say "I have never had one".What is the condition of your teeth? *Great OkayFairPoorWhat is the condition of your eyes? *GreatOkayFairPoorDo you have a mental health diagnosis? *YesNoIf yes, what age were you diagnosed and what is the diagnosis?Females: Are you pregnant? *YesNoI don't know I understand there is a $500 non-refundable intake fee at the time of entry into the NSL program and that monthly fees will be discussed at the time of the interview. *YesNoI understand the NSL program is a drug/alcohol/tobacco-free program and that I will be subject to random drug/alcohol/nicotine testing. *YesNoDo you have any active or pending warrants you are aware of?YesNoSubmit