Men's Regeneration Program

Fill out the application below to begin your journey to a new life. Please ensure the phone number you provide is one we can easily reach you. After reviewing your application, we will give you a call to set up your interview. If you have any questions, please call us at 336-376-5066.

Name

Birthdate

Mobile Phone

This address will receive a confirmation email

SS#

Address

Drug of Choice

Last Day Used

Have you been to rehab before?

Yes No

Marital Status

Do you have children?

Yes No

Child(ren)'s Name

Medical Information

Have you ever been tested for the HIV virus, aids, or hepititus?

Yes No

Do you have any food/pet allergies?

Yes No

List allergies below

Are you currently taking any medications?

Yes No

What are the medications for?

Driver's License Information

Do you have a valid driver's license?

Yes No

State

License Number

Emergency Contact Information

Emergency Contact Name

Emergency Contact Phone

Relationship

Emergency Contact Address

Legal Information

Are you a registered sex offender?

Yes No

Do you have pending court dates?

Yes No

When is your court date?

Are you on probation or parole?

Yes No

What are you on probation/parole for?

Tell us how we can best help you. What are you struggling with? What do you hope to gain by being at Living Free's Men's Regeneration Program?

Living Free Ministries Men's program is a Christian-based Regeneration Program for men battling drug addiction and alcoholism. We are not a medical facility. You are required to handle all personal affairs before entering. You may not leave during your program to handle matters and then come back. If you have any questions about this please ask during your phone interview.

Things to bring: clothing, personal hygiene items, wash cloth, towels, shower shoes, Bible, stamps, paper and envelopes.

Living Free is a tobacco-free facility, any tobacco found at intake will be disposed of. If you bring a cell phone it will be locked away and given back to you when you leave the program. A thorough bag search will be done on the day you arrive.

Are you ready to make this life-long commitment to change your life?

Yes No

Men's Regeneration Program

Description

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