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.
* Required
Email address
*
Your email
First & Last Name
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Your answer
Date of Birth
Your answer
TDOC #
Your answer
Where are you living at this moment? Current Address: Street # & Name, City, State Zip
Your answer
Email
*
Your answer
Phone number
*
Your answer
What treatment programs have you previously attended? Did you complete them?
*
Your answer
Family member contact name
Your answer
Family contact relation
Your answer
Family contact phone number
Your answer
Do you have a history of trauma? Mental, Physical, or Mental
Yes
No
Maybe
Clear selection
Why do think you want to attend TILM?
Your answer
Referred by
Your answer
May we contact them
Yes
No
Clear selection
Have you ever had a relationship with God, Jesus, & Holy Spirit? How would you describe it?
Your answer
Are you currently working?
Yes
No
Clear selection
Are you willing to stop working while at TILM?
Yes
No
Clear selection
Are you currently dependent on/or take drugs or alcohol?
Yes
No
Clear selection
Are you willing to quit smoking or vaping?
Yes
No
Maybe
Clear selection
If you are incarcerated, how long have you been detained?
Your answer
Where are you currently being housed? (Please list name of facility & full address)
Your answer
Do you have charges pending?
Yes
No
Maybe
Clear selection
If yes, what are the charges?
Your answer
Are you on probation or parole?
Yes
No
Clear selection
If yes, what is your probation officer's name, location, and number?
Your answer
If you have children, what are their names, where are they located & in who's care? Who has custody?
Your answer
Do you currently have any cases with DCS? If so, what county?
Your answer
Do you have any health issues
Yes
No
Clear selection
If yes, what are your health issues?
Your answer
Do you have a mental health diagnosis?
Yes
No
Clear selection
What age were you diagnosed and what is the diagnosis?
Your answer
Are you on any medications for mental health or physical health? Please specify brand and reason for use?
Your answer
Are you pregnant?
Yes
No
Maybe
Clear selection
Is there anything else you believe we need to know prior to your interview or review for acceptance into our program?
Your answer
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