Freedom Home Application – Family Care Ministries

Please be sure you have enough time to complete the application in one sitting. There is no save-and-return point. We will respond to all applications as soon as possible. Thank you.

Full NameEnter your full legal birth name.

AgeEnter your age. You may either type the number or use the up/down arrows in the box.

Birthdate *

Choose your birthday using the calendar tool provided.

Height *Enter your height using feet and inches.

Weight *Enter your approximate weight.

Gender *MaleFemaleSelect your birth gender.

Social Security NumberEnter your 9-digit social security number using hyphens to separate the fields.0 / 15

Street Address *Enter your primary street address.

Apartment, Unit, etc.Enter your apartment, unit, or suite number, if applicable

City *Enter your primary address city.

State *Enter your primary address state using the two-letter code.

Zip Code *Enter your primary address zip code.

CountryEnter your primary address country.

Phone *Enter your primary phone number, if applicable.

U.S. Citizenship *YesNoAre you a U.S. citizen?

Marital Status *MarriedSingleDivorcedSeparatedPlease select the option that describes your status.

Which whom are you currently living? If you live alone, enter "live alone." *

Do you have any tangible property? *YesNo

Do you have a health insurance policy? *YesNo

Do you have any income, or do you expect to receive any while you are in our program? *YesNo

Do you have any money in a savings, checking, or personal account? *YesNo

If yes, which type of account and how much?Please enter any account(s) and their approximate amount(s).

Do you have any outstanding debts? *YesNo

If yes, how much?Please approximate how much collective debt you have, if applicable.

Are you involved in any of the following?

pornographyhomosexualitybestialityprostitution

Select any that may be applicable. You may select more than one or nonoe at all.

Are you a high school graduate? *YesNo

Are you currently employed? *YesNo

Have you been in the military? *YesNo

Have you been in institutions (medical, penal, etc.) before? *YesNo

Have you ever been involved in an occult? *YesNo

Do you like yourself? *YesNo

If we asked your family members the question below, how do you think they would most likely respond? *YesNoDoes he/she lie when he/she feels the need to do so?

If we asked your family members the question below, how do you think they would most likely respond? *YesNoIs he/she honest?

If we asked your family members the question below, how do you think they would most likely respond? *YesNoIs he/she a manipulator?

If we asked your family members the question below, how do you think they would most likely respond? *YesNoDoes he/she usually blame others for his/her actions?

If we asked your family members the question below, how do you think they would most likely respond? *YesNoWill he/she steal if given the opportunity?

If we asked your family members the question below, how do you think they would most likely respond? *YesNoHas he/she ever stolen from you?

Are you currently on probation or parole? *YesNo

Probation/Parole Officer NameEnter the name, if applicable.

Officer PhoneEnter the officer phone number, if applicable.

Officer Street AddressEnter the officer street address, if applicable.

Suite, Room, Office, etc.Enter the officer sub-address, if applicable.

CityEnter the officer street city, if applicable.

StateEnter the officer street state, if applicable.

Zip Code

Do you have any upcoming court appearances for any reason? *YesNo

Do you have an attorney? *YesNo

Attorney NameEnter your attorney's name, if applicable.

Attorney PhoneEnter your attorney's phone number, if applicable.

Do you regularly attend religious services? *YesNo

Have you committed your life to Jesus Christ? *YesNoPlease answer the question.

Are you aware that the Freedom Home believes that only a personal relationship with Jesus Christ can help you overcome your life-controlling problems? *YesNo

Are you ready and willing to allow Jesus to work in your life? *YesNo

Do you understand that you will be confronted regarding issues in your life, and that we will not apologize for doing so? *YesNo

How desperately do you need help? *Extremely DesperateSomewhat

Do you agree that your ways have not worked and that you need a complete change of lifestyle? *YesNo

Do you understand that in the event you are found to have tobacco, drugs, or alcohol in your possession while in the program, you will face immediate dismissal? *YesNo

Are you aware that if at any time our staff determines that you are not interested in our training procedures, you will be released from the program? *YesNo

Do you understand our policy regarding family members with whom you may communicate? *YesNo

Do you understand that you will have limited contact with your family during the program? *YesNo

Does your family know you are applying to the Freedom Home? *YesNo

If accepted, are you willing to commit six (6) months to the program? *YesNo

Do you have any teeth cavities or other dental problems? *YesNo

If yes, please describe.Please detail any dental issue, if applicable.

When were your eyes last checked? *Please list the timeframe since your last eye exam. If unsure, enter "Unsure." If you've never had one, enter "Never."

How are your eyes? *Good FairPoor

Are you currently using any prescribed medications? *YesNo

List your current medications, if applicable. *Please list any medicines you currently take. If none, enter, "None."

Are you aware that the Freedom Home is not a licensed, professional drug/alcohol treatment program or a medical or mental-health facility? *YesNo

When did you last do an illegal drug? *Please enter the timeframe since you last used a drug(s), if applicable. If never, enter "Never."

If yes, what was it?Please list the illegal drug name(s), if applicable.

Do you feel that you will require medical treatment for drug/alcohol withdrawals? *YesNo

Did you complete this application yourself, or did someone else do it for you? *SelfSomeone else

Do you have a problem signing numerous liability releases before being admitted to our program? *YesNo