Name
*
First Name
Last Name
Date
*
MM
DD
YYYY
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email
*
Phone
*
(###)
###
####
Date of birth
*
MM
DD
YYYY
Age
*
Height
*
Weight
*
What is your reading level?
*
Excellent
Very well
Good
Ok
Poor
Social Security Number
*
Drivers License Number
Marital Status
*
Single
Married
Divorced
Widowed
Engaged
If married, what is the name of your spouse?
First Name
Last Name
If you have children, what are their names?
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Number
*
(###)
###
####
Have you ever had convulsions, seizures, or blackouts?
Yes
No
List any allergies you may have
Do you have heart disease, diabetes, epilepsy, respiratory disease, etc.?
*
Yes
No
Do you have a Naltrexone Implant?
Yes
No
Do you have a doctor?
*
Yes
No
Doctor's Name?
First Name
Last Name
Doctor's phone number
(###)
###
####
Do you have medical insurance?
*
Yes
No
Insurance Policy Number
Electronic Signature
*
This certifies that all information you have entered is correct to the best of your knowlege.
First Name
Last Name
Date
MM
DD
YYYY
Legal Issues
List all pending court dates, jail terms, Charges, etc.:
Are you ordered by the court to enroll in this program?
*
Yes
No
Are you under bond?
Yes
No
If yes, which county?
If yes, which state?
Do you have a probation officer?
Yes
No
Probation Officer's Name?
First Name
Last Name
Probation Officer's Phone Number
(###)
###
####
Do you have an attorney?
Yes
No
Attorney's Name
First Name
Last Name
Attorney's Phone Number
(###)
###
####
Sign here to authorize Changed Lives Ministry to a background check, consult with your Probation Officer and/or your attorney regarding your legal situations:
*
First Name
Last Name
Date
MM
DD
YYYY
Thank you!
Your application has been received, and we are grateful for the opportunity to walk alongside you on this path of spiritual growth and healing. We believe that God has a special plan and purpose for each individual who seeks His guidance and restoration.
At Changed Lives Ministry, we understand the power of God's grace and redemption, and we are committed to providing a supportive and compassionate environment for individuals like yourself. Our dedicated team is earnestly reviewing your application, seeking God's wisdom and discernment in determining the best way to support you.
During this time of waiting, we encourage you to draw near to the Lord, seeking His guidance and strength. In His presence, there is hope, comfort, and reassurance. Take solace in knowing that we are fervently praying for you, lifting your needs and desires before our Heavenly Father.
Should you have any questions, concerns, or simply desire further support, we are here for you. Our doors and hearts remain open, ready to serve and guide you as you navigate this transformative journey.
Once again, we thank you for choosing Changed Lives Ministry. We believe that God's hand is upon you, and we are honored to be a part of your story of healing, restoration, and renewed hope. May the Lord continue to guide and bless you abundantly.
In His love and grace,
The Change Lives Ministry Team
