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Personal Information

First Name *

Last Name *

Email *

Phone *

Present Address *

City

Postal Code

Country

Birthday *

How did you hear about us?

Marital Status

Do you have children?

Yes

No

Health Information

Do you have allergies?

Yes

No

Are you on any medications?

Yes

No

Substance & Diagnosis History

Mental Health History

Faith & Goals

Did you grow up in a Christian Faith group?

Yes

No

What is your present relationship with Jesus Christ?

Why would you like to come to Homestead for Hope?

What would you like to see happen in your life while here?

Agreement

I understand the Choose Life Ministry is a Christian faith based organization and recognize that this topic will guide the program. I agree to comply with the standards and co-operate with the staff of Choose Life Ministry.

I understand that if I have not answered these questions truthfully or have knowingly withheld any information, it may be considered grounds for refusal to the program or discharge from the program due to noncompliance.