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Let’s start with something easy

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Enter your name

Date of Birth

Enter your email*

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Personal Information

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Street Address

City, State, Zip Code

Phone Number

If divorced or separated, was drug abuse a facor?

Yes

No

If yes, please explain

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Additional Personal Info

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Place of Employment

Job Title

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Family Status

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Do you have children?

Yes

No

If yes, what are their ages?

Do you have custody or visitation with your children?

Yes

No

Has your custody and/or visitation with your children ever been revoked because of drug use?

Yes

No

If yes, when and please explain?

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Health Status

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Have you ever been diagnosed with a mental or physical illness?

Yes

No

If yes, what was your diagnosis?

What doctor prescribed medication or treatment are you currently using?

Do you currently have or had in the past any contractual disease such as Hepatitis, HIV, Herpes, or other?

Yes

No

If yes, please explain?

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Health Status

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Are you a registered sex offender?

Yes

No

Do you have any pending charges related to sex crimes?

Yes

No

If yes, please list the charges and city and state?

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Past/Present Drug Use

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How old were you when you first used drugs? Which drug/s did you use?

Describe how you were first introduced to drugs?

Name all of the drugs you have used in your lifetime and when you last used it. Begin with the most recent.

What drug/s, including prescribed medications, have you used in the last 12 months?

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Past/Present Drug Use

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If you abused Opiates (oxycodone, painkillers, ect), how many did you take a day? How long since you used?

Was there drug abuse in your home while you were growing up?

Yes

No

If yes, which drugs?

Were you abused (physically, sexually, emotionally) during your childhood or adolescent years?

Yes

No

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Effects of Drug Use

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Have you ever been arrested or incarcerated for drug use, possession, or intent to manufacture or sell?

Yes

No

If yes, which year/s? What were you accused of?

Are you on probation or out of jail on bond for any drug-related crime?

Yes

No

If yes, who is your probation officer and when do you return to court?

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Effects of Drug Use

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Do you still have close friends and/or family who use drugs?

Yes

No

When and where have you been to counseling or rehab?

What did you like or dislike about the drug rehabilitation program?

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Effects of Drug Use

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What do you think is the solution to your drug problem?

What negative effect has your drug problem had on your life

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Effects of Drug Use

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Has drug abuse contributed to any of the above episodes?

Yes

No

If yes, please explain.

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Program Expectations

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How did you hear about The Hope Movement?

Why are you applying for The Hope Movement?

What do you expect the outcome to be if you are accepted and complete the program?

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Religion/ Spirituality

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Do you believe in God?

Yes

No

If no, have you ever believed in God?

Yes

No

Have you ever been involved witchcraft, tarot card readings, or any other occult religion?

Yes

No

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Religion/ Spirituality

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Do you believe Jesus Christ is God's Son?

Yes

No

Do you believe that Satan exists?

Yes

No

Do you believe in Heaven and Hell?

Yes

No

Do you understand God's plan of salvation?

Yes

No

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Religion/ Spirituality

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Do you understand God's plan of salvation?

Yes

No

If yes, please explain.

Have you ever confessed your sins and asked Jesus to forgive you and be Lord of your life?

Yes

No

If yes, please explain.

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Finally, confirm your availability

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Country

Preferred date for chat

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Let’s start with something easy

Personal Information

Additional Personal Info

Family Status

Health Status

Health Status

Past/Present Drug Use

Past/Present Drug Use

Effects of Drug Use

Effects of Drug Use

Effects of Drug Use

Effects of Drug Use

Program Expectations

Religion/ Spirituality

Religion/ Spirituality

Religion/ Spirituality

Finally, confirm your availability

Transforming Lives Through Hope and Healing