Life Institute Application
Victory Mission’s new Life Institute is an outreach of Victory Mission + Ministry. Through this ministry we want to provide a safe and supportive environment for individuals to engage in life restoring classes and services.
Through all of our services and programming at Victory Mission, it is our intention to live out our commitment to sharing God’s love through intentional relationships and opportunities for life restoration. We want to do more than sustain you in a difficult situation. We want to offer opportunities, resources, and support to help you transform your life and live out of your true God-given value and purpose.
To help provide opportunities for holistic healing in your life through Victory Life Institute, we will invite you to share with us openly about your unique situation and to fully participate in classes, case management, and counseling services offered free of charge. Evening classes will be followed by a healthy meal.
We will offer classes in the following holistic areas:
Personal | Relational | Vocational | Spiritual | Financial
Life Institute Classes for participants will take place on at Victory Mission’s administrative building on
Monday - Thursday nights on an 8-week rotation with the following evening schedule:
4:30 - Chaplain Check In
5:00 - Classes Start
6:00 - Dinner Distributed
All interested in applying to the Life Institute must be willing to fully participate in the following:
Interview for the program
Attend evening classes
Meet with a VM case manager
Meet with a VM counseling intern
Behavior that harms others or puts others or staff at risk will not be tolerated. To help provide a safe and healthy environment, the following types of behaviors (partial list) will not be tolerated:
Intoxication/Under the Influence of Drugs, Abusive Language/Profanity, Panhandling, Making False Accusations, Assault/Attempted Assault, Theft/Possession of Stolen Goods, Entry in Unauthorized Areas of the Building, Vandalism/Defacing Property, Any Illegal Transaction, Verbal/Physical Intimidation, Any Sexual Misconduct, Smoking Outside Designated Area, and Weapons (weapons may be checked in with security).
Programming will adhere to guidelines to help reduce risks of COVID-19 spread in the community. You will be asked to wear a mask, participate in a temperature check, maintain the recommended 6 ft. social distancing, and do all that you can to protect yourself and those around you from the spread of disease.
If you are interested in being a part of the new Life Institute, please fill out an application (in its entirety). A chaplain will reach out to you if you have been admitted to this life-changing program!
I have read and understood the statement above:
First Name (Legal)
Last Name (Legal)
Preferred Name (if different than Legal)
Date of Birth
Best Way to Contact You?
Romantic Relationship Status
Emergency Contact Name (First & Last)
Emergency Contact Phone #
Emergency Contact Relationship
Do you have a photo ID?
Have you ever been barred/suspended from Victory Mission (this will not necessarily keep you from attending)?
Have you ever had a mental health diagnosis or treatments?
If yes, what is your mental health diagnosis (and when were you diagnosed)?
Are you currently taking any medications?
What medications, if any, are you taking?
Are any of these legal situations applicable (check all that apply)?
Active Court Case(s)
Convicted and/or Registered Sex Offender
None of the Above
If you answered yes to any of the legal questions or have any other current legal issues, please share details.
Do you have a history of any of the following (check any that might apply)?
None of the Above
If you answered yes to any of the situations above, please tell us a bit more about your journey of healing.
Please describe your current/past experience with faith, church, or religion of any kind.
Are you currently consistently involved with a faith community?
If you currently attend a faith community, which one do you attend? How are you involved with your church?
Rate Your Current Overall Situation
Worst Situation Possible
Best Situation Imaginable
Please tell us a little bit about the situation you are facing right now.
FOOD ACCESS (best description)
1) No food or way to prepare food (depend on free food resources)
2) Can meet most food needs with my SNAP benefits
3) Can usually meet basic food needs but sometimes need a little help
4) Can usually meet basic food needs without any help
5) Can choose to purchase any food for my household with available income
HOUSING SITUATION (best description)
1) Currently Homeless (example: homeless shelter, on streets, in vehicle, or staying with friends)
2) Transitional Housing (example: hotel, motel, short-term lease, or no working utilities)
3) Permanent Housing needs lots of repairs (example: HUD/Section 8 or in need of major repairs
4) Permanent Housing adequate but can't afford it (almost 1/2 my income is used for housing)
5) Permanent Quality Affordable Housing (a safe place I can afford)
TRANSPORTATION (best description)
1) No Transportation or vehicle does not run
2) Unpredictable Transportation (example: borrowing a car, limited bus access/money)
3) Vehicle Access but needs major repairs or has no license/insurance
4) Own Vehicle but needs small repairs or do not have money for gas
5) Transportation Fully Available (example: money/access for bus, working vehicle, car insured)
EMPLOYMENT (best description)
1) Unemployed or Never Worked
2) Unemployed for less than 3 months
3) Part-time Employment (20 hours a week or less)
4) Full-time employment without benefits (30 hours a week or more)
5) Full-time employment with living wage and benefits (30 hours a week or more)
INCOME/BUDGET (best description)
1) No Regular/Consistent income
2) Income does not meet basic needs
3) Income meets basic needs but no money for emergencies
4) Income meets basic needs and a little left over for small emergencies
5) Income meets needs and allows for extras and savings
Household Monthly Income Amount (including SSI/SSDI, Child Support income, etc.):
PERSONAL & COMMUNITY SUPPORT (best description)
1) No supportive people in my life & don't know about community resources
2) No supportive people in my life but I know some community resources
3) 1-2 supportive people in my life and know community resources
4) 3-5 supportive people in my life & work with 1+ community resources
5) 5+ supportive people in my life & active in community resource help
COMMUNITY INVOLVEMENT (best description)
1) No community involvement because of difficult life situations
2) Isolated or anxious about getting more involved in community
3) Not sure how to get more involved in my community
4) Involved in community but can't go because no transportation
5) Actively involved in my community (ex: support groups, church)
EDUCATION (best description)
1) Some High School
2) High School Diploma/GED
3) Attended College
4) Associates/Technical Trade School Degree Attained
5) Bachelor/Master/Doctorate Degree
MENTAL HEALTH/ SUBSTANCE ABUSE (best description)
1) My mental health and/or substance abuse CONSISTENTLY keep me from my job/goals
2) My mental health and/or substance abuse REGULARLY keep me from my job/goals
3) My mental health and/or substance abuse SOMETIMES keep me from my job/goals
4) My mental health and/or substance abuse DOES NOT keep me from my job/goals
5) There are no mental health or substance abuse problems for me at this time
PHYSICAL HEALTH (best description)
1) My health problem CONSISTENTLY keep me from getting a job
2) My health problem REGULARLY keep me from my job/goals
3) My health problem OCCASIONALLY keep me from my job/goals
4) My physical health problem DOES NOT keep me from my job/goals
5) There are no physical health problems for me at this time
PSYCHOSOCIAL/ENVIRONMENTAL STRESSORS (best description)
1) Current stressors are so OVERWHELMING that I am unable to focus on job/goals
2) Current stressors CONSIDERABLY affect my ability to focus on job/goals
3) Current stressors MODERATELY affect my ability to focus on job/goals
4) Current stressors only MINIMALLY affect my ability to focus on job/goals
5) Stressors do not keep me from a job/goals
I receive the following supportive government benefits (check all that apply):
Social Security Income
Social Security Disability Income
TANF (Temporary Assistance for Needy Families)
None of the Above
Is there anything we can pray for you about or anything you would like us to know?
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This form was created inside of Springfield Victory Mission.