NEW BEGINNINGS MINISTRIES APPLICATION

You must be at least 18 years of age to enter the ministry.

YOUR COMMITMENT

The first 60 days of your stay at New Life Ministries is filled with many challenges. This most often includes homesickness, struggles with trust, environmental changes, and a roller coaster of emotions. The first inclination of the resident is the desire to leave prematurely before the adjustment period is complete. We have found that after the first 60 days, most of this insecurity passes.

Unfortunately, ladies walk away from their opportunity with New Life Ministries because they do not give themselves enough time to make the necessary adjustments. With this in mind, we are requiring a strong commitment on your part to enter this ministry with a determination in your heart to see it through to the end. Your signature to this commitment form is your agreement not to compromise your decision to change, and, therefore, agree to give no time or expression to ideas such as: "I'm too homesick," "This is too hard," "I'm not ready for this" or "I don't want God shoved down my throat." We understand that feelings of homesickness and missing your family is valid; however, you must determine that you will not allow these feelings to drive you from your commitment to what God has for you through New Life Ministries.

Your name and signature below represent your commitment and desire to do what it takes to achieve freedom and healing. We are committed to you as long as you are committed to Jesus and His change in your life.

IF YOU DO NOT AGREE TO THIS COMMITMENT, PLEASE DO NOT PROCEED WITH THE APPLICATION PROCESS.

If you do agree, please sign and proceed with the Application.

Name(Required)

First Middle Last Maiden

Signature

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

County you will be entering NBM from(Required)

Attending(Required)

Voluntary

Mandated

Phone # for interview(Required)

Date of Birth(Required)

Your Age(Required)

Social Security Number(Required)

Referred by(Required)

Their Phone Number(Required)

Name of Contact person if at Facility(Required)

Their Phone Number(Required)

In case of Emergency notify:(Required)

Relationship to You(Required)

Their Phone Number(Required)

BACKGROUND INFORMATION

Drug of choice(Required)

Living Situation(Required)

Non-Housing (street, car, etc.)

Mother transient, children living with relatives/friends

Domestic Violence situation

Mother and children living with relatives/friends

Emergency Shelter

Transitional Housing for homeless persons

Describe most recent living situation, choose most applicable.

If Transitional Housing for homeless persons,(Required)

Psychiatric Facility

Substance Abuse Treatment Facility

Hospital

Jail/Prison

Rental Housing

Own Home

Other

Have you ever been in a lesbian relationship?(Required)

Yes

If yes, for how long?

Have you ever been involved in prostitution?(Required)

Yes

If yes, for how long?

Have you ever been involved in any satanic cults or rituals?(Required)

Yes

If yes, please explain

FAMILY

Marital Status(Required)

Single, never married

Married

Divorced

Widowed

If widowed, how long

How did he die?

Please list all the names and ages of children. Include details of any special needs, medication, or behavioral problems. In addition, please state your goals for your children and whether you have custody of your children:(Required)

Please list any service agencies/provider (and contact persons) that work with you. Include their address and phone numbers, attorneys, DFCS, probation/parole, department SS, etc.:(Required)

INCOME

List all income sources and amounts you receive from each.

Employment Income Amount:

General Public Assistant Amount:

Unemployment Benefits Amount:

Supplemental Security Income (SSI) Amount:

Disability Income (SSDI) Amount:

Social Security Amount:

Veterans Benefits Amount:

Medicare Amount:

Medicaid Amount:

WIC Amount:

Child Support Amount:

Other:

(Please specify) $

Total Monthly Income(Required)

EDUCATION

High School Disploma/GED(Required)

Yes

If No, what is the highest grade completed?

College/Tech:(Required)

Educational Interest(Required)

My Personal Goal & Dream is to:(Required)

EMPLOYMENT HISTORY (start with most recent)

Employer #1(Required)

Please provide Employer Name, Dates of employment (to/from), Address, Job Title, Job Description, Reason for Leaving

Employer #2

Please provide Employer Name, Dates of employment (to/from), Address, Job Title, Job Description, Reason for Leaving

Employer #3

Please provide Employer Name, Dates of employment (to/from), Address, Job Title, Job Description, Reason for Leaving

HEALTH & WELLNESS

Do you have a history of the followng?(Required)

Mental Illness

Alcohol Abuse

Drug Abuse

Depression

Probation or Parole

Development Disability

Physical Disability

Domestic Violence (as an adult)

HIV/AIDS and related diseasaes

Agencies worked with(Required)

Please list any service agencies/providers (and contact persons) that work with you, along with their addresses and phone numbers:

HEALTHCARE

Date of last Medical Exam:(Required)

Diagnosis:(Required)

Have you been tested for any of the following?(Required)

Diagnosis:(Required)

For each item checked, indicate Neg or Pos. If STDs were Pos, what was it for?

Recent Pap(Required)

Yes

Please describe any physical disabilities NBM would need to provide assistance for:(Required)

We live in a rural area and take care of the house and grounds. Are you able to perform:(Required)

Housekeeping chores, such as vacuuming, mopping, laundry, dusting, cooking, cleaning, etc.

Yard/garden work such as raking, hoeing, planting, weeding, etc.

If you are unable to perform any of the chores, what is the reason?

Are you able to climb stairs?(Required)

Yes

Do you have insurance? If yes, who is the provider?(Required)

Do you have a primary physician?(Required)

Indicate Doctor's name, address, and phone number

Please list all Medical Conditions(Required)

Including Mental Health conditions and diagnosis, Treatments, and Current Medication. Please be aware that if you have or develop any medical condition lasting more than two weeks, you will need to look for another placement as NBM is not a medical facility and is unable to provide convalescent or medical treatment on-site.

Please list all medications you are current on and the reason for taking them:(Required)

Have you ever applied for SSI or Disability? If so, when and why?(Required)

LEGAL HISTORY

Are you currently on probation/parole? If Yes, for what charge(s)?(Required)

Provide name and phone number for probation/parole officer(s):

What current charges are pending?(Required)

What is the nature of your current and past charges?(Required)

Please include for each Date, Place of Arrest, Nature of Charges, Arrests, Outcome, and Time Served

LEVEL OF COMMITMENT

Are you a born again Christian?(Required)

Yes

Do you realize that you are coming into a heavily Christian Oriented program?(Required)

Yes

Do you believe the Bible to be the infallible and inspired word of God?(Required)

Yes

Do you want to change the way you are living?(Required)

Yes

Are you coming here because YOU want to?(Required)

Yes

Are you committed to our 12-month discipleship ministry?(Required)

Yes

How do you feel about participating in community living?(Required)

How do you feel about community living?(Required)

How do you see our ministry enabling you to become self-sufficient?(Required)

How do feel about any necessary rules and restrictions as a resident?(Required)

Please express as completely and honestly as you can, why you would like to be a resident at New Beginnings Ministry and how you feel you could benefit from being involved in our ministry:(Required)

Agreement And Contract For Program And Guidelines

New Beginnings ministry is a Christ Centered Ministry. There are requirements that must be met by each resident that wishes to enter and remain here at New Beginnings.

The Ministry is as follows and includes but is not limited to:
13 Church Services a week, 7am-9am and 7pm-as late as 9pm (excluding most Friday evenings). Depending on the nature of the week, we may be in church more than 13 times a week, and more than 3 hours in the evening.

- Group counseling where a client will be asked and required to participate, share openly, and honestly in front of others.
- Inner Healing using Biblical applications
- Will not be able to act on ANY sexual tendencies, and displays of affection towards another client, such as Note passing, Touching, Hugging, Giving gifts of any kind, 3rd party messages. You will guard yourself from isolation with the one that you are attracted to.
- NBM is an abstinence based program, smoke free/nicotine free, and caffeine free.
- Tylenol and Advil are dispensed on a vaery limited basis. Medical condition will be assessed by the RN on duty.
- Every other weekend (but not limited) is work Saturday and each client will be assigned a specific detail.
- There are daily chores assigned to each resident that they are to be for. (Failure to do so will result in restriction.)

Type and Sign Your Name Below(Required)

First Last

Signature(Required)

Date(Required)

AGREEMENT NOT TO BE UNDER THE INFLUENCE OF ANY SUBSTANCE

I, the undersigned, understand that by entering New Beginnings Ministry that I am not under the influence of any mood- or mind-altering substances. NBM is not a detox center or a rehabilitation program. We are simply a place to obtain healing and become the woman that God called you to be.
This will be accomplished on through thew power of the Holy Spirit and a willingness to surrender and completely abandon yourself over to a loving God.
If you are willing to allow God to take you through your past and bring healing to your life, you are in the right place. By signing below, you are saying Yes to a journey of redemption and healing. It is only by the Blood of Jesus Christ that we are saved.

YOUR NAME AND SIGNATURE BELOW INDICATE YOUR UNDERSTANDING OF THIS AGREEMENT(Required)

First Last

Signature(Required)

Include below any additional comments or concerns you might have:

NEW BEGINNINGS MINISTRIES APPLICATION

YOUR COMMITMENT

IF YOU DO NOT AGREE TO THIS COMMITMENT, PLEASE DO NOT PROCEED WITH THE APPLICATION PROCESS.

BACKGROUND INFORMATION

FAMILY

INCOME

EDUCATION

EMPLOYMENT HISTORY (start with most recent)

HEALTH & WELLNESS

HEALTHCARE

LEGAL HISTORY

LEVEL OF COMMITMENT

Agreement And Contract For Program And Guidelines

AGREEMENT NOT TO BE UNDER THE INFLUENCE OF ANY SUBSTANCE

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