Initial Application - This is Living
Would you like to apply online or be contacted to ask questions about our program? Please fill out the form! The applicants who are admitted to our program are first interviewed by the director. The director will go over rules and regulations and make a determination of an applicant's readiness to attend TILM's 12 month reentry program. Please complete all information below and our team will be in touch for an initial phone interview. Thank you for your interest in our program.
Email address *
First & Last Name *
Date of Birth
Where are you living at this moment? Current Address: Street # & Name, City, State Zip
Email *
Phone number *
What treatment programs have you previously attended? Did you complete them? *
Family member contact name
Family contact relation
Family contact phone number
Do you have a history of trauma? Mental, Physical, or Mental
Clear selection
Why do think you want to attend TILM?
Referred by
May we contact them
Clear selection
Have you ever had a relationship with God, Jesus, & Holy Spirit? How would you describe it?
Are you currently working?
Clear selection
Are you willing to stop working while at TILM?
Clear selection
Are you currently dependent on/or take drugs or alcohol?
Clear selection
Are you willing to quit smoking or vaping?
Clear selection
If you are incarcerated, how long have you been detained?
Where are you currently being housed? (Please list name of facility & full address)
Do you have charges pending?
Clear selection
If yes, what are the charges?
Are you on probation or parole?
Clear selection
If yes, what is your probation officer's name, location, and number?
If you have children, what are their names, where are they located & in who's care? Who has custody?
Do you currently have any cases with DCS? If so, what county?
Do you have any health issues
Clear selection
If yes, what are your health issues?
Do you have a mental health diagnosis?
Clear selection
What age were you diagnosed and what is the diagnosis?
Are you on any medications for mental health or physical health? Please specify brand and reason for use?
Are you pregnant?
Clear selection
Is there anything else you believe we need to know prior to your interview or review for acceptance into our program?
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This form was created inside of This is Living Ministries.