LIVING HOPE INTERNATIONAL MINISTRY, INC.
NEW BEGINNINGS HOME RESIDENT REQUEST INITAL INTAKE FORM
Please fill all answers completely. Forms not completely filled out may not be considered for acceptance into the Living Hope Ministries' New Beginnings Home program.

Personal Information: Ms. Miss Mrs. Dr. Rev. Rev. Dr. Title Last Name First Name Address  Address 2 City, State ZIP Code Phone E-Mail Age:         No. of children:  My Current Residence is: In the community Jail Prison If you are currently incarcerated, how long is your sentence?    Client Substance Abuse History Please check all that apply. Alcohol     Cocaine    Heroine   Prescription Drugs   Crystal Meth Ecstacy    Other (please specify) If you have a problem with alcohol: How long since your last drink?  Have you ever been in treatment (rehab, AA, etc.) for your alcohol addiction?   select Yes, I have had previous treatment for alcohol No, I have not had treatment for alcohol abuse If you answered yes to the previous question, please give details (treatment dates, rehab facilities, programs, etc.): Are you currently on any prescription medications?   select Yes No If you just answered yes, please describe the illness and medications.   Law Enforcement History Please answer all questions honestly and to the best of your ability. Have you ever been arrested?     select Yes No Have you ever been convicted of a crime?     select Yes No If you answered yes to the previous questions, please give details (charges, city where arrest(s) took place, probationary stipulations, etc.): I was referred to this program by   . Additional comments:       Thank you for your submission. You will be contacted within three business days.