Application

Application for Admittance

Please understand that your acceptance to New Beginnings Ministry requires a 12 months minimum commitment
You must be at least 18 years of age to enter the ministry

Your Commitment

The first 60 days of your stay at New Beginnings 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 Beginnings 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 Beginnings.

Your signature represents 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.

Do you agree with the above commitment and wish to apply?

Yes I accept the terms of the commitment.

General Information

First Name

Last Name

Middle Name

Maiden Name

Street Address

City

State

Zip

County you will be entering NBM from

County

Attending

Voluntary Mandated

Telephone for Interview

Your Date of Birth

Your Age

Social Security Number

Referral & Emergency Contacts

Referred by

Reference Phone

Name of contact person if at facility

Incase of emergency notify

Emergency contact relation

Emergency contact phone

Background

Please list all substances your have used including tobacco. Include the drug, age of 1st use, frequency, date of last use and longest period of abstinence.

Living Situation

Have you ever been in a lesbian relationship?

Yes No

If yes, how long?

Have you ever been involved in prostitution?

Yes No

If yes, how long?

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

Yes No

If yes, please explain.

Family

Marital Status

Single, never married Married Divorced Widowed

If widowed, how long and how did your husband die?

Do you have children?

No Yes

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.

PLEASE BE ADVISED THAT IF YOU HAVE A DFCS/DDS CASE THAT WILL REQUIRE TRANSPORTATION PROVIDED BY NBM WE WILL NOT GO OUTSIDE OF A 80 MILE RADIUS

Do you have custody of your children?

Yes No

Please list any service agencies/provider (and contact persons) that work with you. Inlude their address and phone numbers. Attorneys, DFCS, probation/parole, dept SS, etc.

Income, Employment & Education

List any sources of income or support you have.

Do you own a vehicle?

Yes No

Kelly Blue Book value of vehicle

Total Monthly Income

Highschool Diploma

Highest Grade Completed

Highest Level of College

Educational Interest / Area of Study

My personal goal and dream is to:

Employment history (start with the most recent) include: employer name, employed dates, address, job title, job description, reason for leaving in each entry.

Health & Wellness

Do you have insurance and if yes, who is your provider?

Do you have a primary care doctor?

Doctor's name?

Dr. address and phone

Which of the following do you have a history of?

Mental Ilness Alchohol Abuse Drug Abuse Depression

Date of last medical exam:

List anything you have been tested for and the results. (HIV, HepA, HepB, HepC, TB, etc)

Please describe any physical disabilities we would need to provide assistance for.

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

Housekeeping chores (vacuuming, moping, laundry, dusting, cooking, cleaning, etc.

Yes No

Yard/garden work (raking, hoeing, planting, weeding, etc.)

Yes No

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

Are you able to climb stairs?

Yes No

Are you able to sleep on a top bunk?

Yes No

Please list all medical conditions (including mental health conditions and diagnosis) treatments, and current medications that you are prescribed: 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 medical facility and is unable to provide convalescent or medical treatment on-site.

If you are currently taking any medications please list them below and your reason for taking each.

Have you ever applied for SSI or disability? If so, when and why?

Legal History

Are you currently on probation/parole?

Yes No

If yes, for what charge?

Name and phone number of probation/parole officer(s):

Do you have current charges pending?

What are the charges?

Where were the charges obtained?

When is your next court date/dates?

What is the nature of your current and past charges?

Additional Questions

Are you a born again Christian? (Born Again- asked for forgiveness, repent turning away from old life, walking in transformation by the renewing of your mind. A heart change following Jesus .)

Yes No

If so briefly describe your experience.

If you are not a Christian, we welcome all those who have a sincere desire to change.

Do you realize that you are coming into a heavily penticostal christian oriented program?

Yes No

Do you believe the bible to be the infallible and inspired word of God?

Yes No

Do you want to change the way you are living?

Yes No

Are you coming here because YOU want to or because you have to?

Want to Have to

Are you committed to our 12-month discipleship ministry?

Yes No

How you feel about participating in community living?

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

How do you feel about any necessary rules and restrictions as a resident?

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:

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. (Please check the box to show you've read an agree next to each).

13 church services a week - Depending on the nature of the week we may be in church more than 13 times a week and more than 3 hrs 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 . NBM is an abstinence based program, smoke free/ nicotine free, and caffeine free. Tylenol and Advil are dispensed on a very limited bases. Medical condition will be accessed 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.

I understand that by entering New Beginnings Ministry that l am not under the influence of any mood or mind altering substances. NBM is not a Detox Center, but we are a rehabilitation program to address your addiction and the root of that addiction. We believe that only true lasting recovery can and will only be accomplished through the 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 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. PLEASE SIGN BELOW INDICATING YOUR UNDERSTANDING OF THIS AGREEMENT:

Agree Disagree

Application for Admittance

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