Men's Enrollment / Referral Form - The Fix Ministry

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Get Help
- Men’s Enrollment Form
- Women’s Enrollment Form
About
Fix Thrift
Programs
Partners
Testimonies
Volunteer
Contact

Men’s Enrollment / Referral Form

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Men’s Enrollment / Referral Form

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MEN'S HOME APPLICATION

If you are human, leave this field blank.

General Information

First Name

Last Name

Middle

Current Address

Street Address

Street Address Line 2 (Optional)

City

State/Province

Zip/Postal

Email

Phone

Date of Birth

Gender

M

F

Are you a U.S. Citizen?

Yes

No

If yes, what state is your residence?

If no, what is your country of residence?

Marital Status

Single

Married

Engaged

Seperated

Divorced

Race

African-American

Caucasian

Hispanic

Native American

Asian

Other

Multi-Cultural

Do you read at a 5th grade level?

Yes

No

Do you have a high school diploma?

Yes

No

Do you have a GED?

Yes

No

Do you have friends or relatives in this program?

Yes

No

Have you been enrolled at The Fix before?

Yes

No

What do you primarily need help with?

Alcohol

Drugs

Other

If other, please explain:

Do you use tobacco?

Yes

No

Have you ever been treated at an addiction recovery facility?

Yes

No

Facility

FACILITY INFORMATION

Facility Name

Address

Street Address

Street Address Line 2 (Optional)

City

State/Province

Zip/Postal

Treatment Date Range:

Reason For Treatment:

Did you complete treatment?

Yes

No

Add another facility Remove facility

How did you hear about The Fix Ministry?

In your own words, tell us why you want to come to The Fix Ministry and the main issues you need to deal with while in the program.

Physical Health

Medical History (Check all that apply to your current and past conditions).

Alcohol Abuse

Asthma

Back Problems

Broken Bones/Sprains

Diabetes

Drug Abuse

Head Trauma/TBI

Heart Condition

Hepatitis

High Blood Pressure

HIV/AIDS

Migraines

Respiratory Problems

Seizures

STI/STD

Tuberculosis

Please list any current medical concerns you may have:

Are you currently being treated by a doctor?

Yes

No

Doctor

PRIMARY DOCTOR INFORMATION

Name

Address

Street Address

Street Address Line 2 (Optional)

City

State/Province

Zip/Postal

Phone

Fax

Treatment Date Range:

Reason For Treatment:

Are you pregnant?

Yes

No

If yes, what is your due date?

Are you allergic to any medications?

Yes

No

If yes, please list them below:

Are you currently being treated with prescribed narcotics?

Yes

No

If yes, please list them below:

Are you currently prescribed any non-psychiatric medications?

Yes

No

Medications

Medication

Reason

Dosage

Add another medication Remove medication

Special Needs

Do you have any type of disability?

Yes

No

If yes, please explain.

Do you have any chronic conditions?

Yes

No

If yes, please explain.

Do you have any medical restrictions?

Yes

No

If yes, please explain.

Do you have any type of special needs?

Yes

No

If yes, please explain.

Do you have any allergies?

Yes

No

If yes, please explain.

Do you require a special diet?

Yes

No

If yes, please explain.

Dental & Vision Health

Do you have any dental issues that need treatment?

Yes

No

If yes, please explain.

Do you wear glasses or contacts?

Yes

No

Do you have your glasses or replacement contacts?

Yes

No

Mental Health

Have you ever been treated for mental disorders?

Yes

No

If yes, when?

Have you ever been treated by a Psychiatrist/Psychologist?

Yes

No

Psychiatrist/Psychologist

PSYCHIATRIST/PSYCHOLOGIST

Name

Address

Street Address

Street Address Line 2 (Optional)

City

State/Province

Zip/Postal

Office Phone

Fax

Treatment Date Range:

Reason For Treatment:

Add another doctor Remove doctor

Are you currently prescribed any psychiatric medications?

Yes

No

Medications

Medication

Reason

Dosage

Add another medication Remove medication

Please tell us of any current medical/emotional health concerns you may have:

Have you thought about or attempted suicide in the past six months?

Yes

No

If yes, when?

Mental Health History (Check all that apply to your current and past conditions).

ADD/ADHD

Anorexia

Anxiety Disorder

Bipolar Disorder

Bulimia

Depression

Hallucinations

Hearing Voices

Homicidal Thoughts/Tendencies

Insomnia

Multiple Personalities

Paranoia

Personality Disorder

Physical Abuse

Post Traumatic Stress Disorder

Rape Victim

Sexual Abuse

Schizoaffective Disorder

Schizophrenia

Suicidal Attempt

Suicidal Thoughts

Legal Issues

Are you currently on probation?

Yes

No

Probation Contact Info

PROBATION CONTACT INFORMATION

State and County of Probation

Probation Officer's Name

Probation Officer's Address

Street Address

Street Address Line 2 (Optional)

City

State/Province

Zip/Postal

Probation Officer's Office Phone

Probation Officer's Cell Phone

Fax

Probation Officer's Email Address

Are you currently on parole?

Yes

No

If yes, list the State and County of your parole.

Do you currently have any court cases pending?

Yes

No

If yes, please provide the information below.

State and County of your hearing(s):

Court dates and nature of charge(s):

Are you currently under investigation?

Yes

No

If yes, list the State and County conducting the investigation.

Do you have any outstanding warrants for your arrest?

Yes

No

If yes, list the State and County of the warrant(s).

Have you ever been convicted of a violent crime?

Yes

No

If yes, list each conviction and date.

Are you currently facing charges for a violent or sex-related crime?

Yes

No

If yes, describe the charges.

Are you required to register as a sexual or predatory offender?

Yes

No

Do you have an attorney?

Yes

No

Attorney Information

ATTORNEY INFORMATION

Attorney's Name

Attorney's Address

Street Address

Street Address Line 2 (Optional)

City

State/Province

Zip/Postal

Office Phone

Cell Phone

Fax

Attorney's Email Address

Legal History (Check all that you have been involved with)

Aiding & Abetting

Attempted Murder

Attempted Robbery

Battery

Credit Card Fraud

Drug Distribution

DUI

DWI

Embezzlement

Fraud

Identity Theft

Larceny/Grand Larceny

Manslaughter

Murder

Parole Violation

Prostitution

Sex with a Minor

Shoplifting

Soliciting Prostitution

Other

If other, please list:

Emergency Contact

Emergency Contact Name

Emergency Contact Relation

Address

Street Address

Street Address Line 2 (Optional)

City

State/Province

Zip/Postal

Email Address

Home Phone

Cell Phone

Work Phone

Financial Information

Are you currently employed?

Yes

No

If yes, where are you employed $

Do you currently receive government assistance?

Yes

No

If yes, what type?

Program Fee Information

An Induction Fee of $750.00 is due at the time of admission. All applicants are responsible for seeking monthly sponsorship for costs beyond what they can afford. It cost The Fix Ministry approximately $1250.00 per month to house each student. Partial scholarships may be available based on financial need. To be considered for a need-based scholarship, please complete the following information as accurately as possible.

I acknowledge and commit to pay the Induction Fee of $750.00. *

Yes

I agree to seek financial help from friends or family

I need financial aid

Text

Check any/all of the following personal assets and income you have and list the value of each:

Certification And Agreement

By my signature below, I certify that all answers and statements on this application are true and complete to the best of my knowledge. I understand that, should an investigation disclose untruthful or misleading answers, I may be discharged from the The Fix program. Furthermore, I understand that The Fix Ministry is a Christian, faith-based program.

Please initial the following lines to indicate that you have received, read, and agree to abide by the program guidelines listed below.

Text

Program Policies and General Information

Text

Room and Board Fee Information

Text

Prohibited Medication

Text

Applicant Electronic Signature

Date

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