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Women wishing to enter the residential treatment program may now apply by downloading the application form or completing the online application form below.

Please submit downloaded application forms to:

E: Executivedirector@chooselifeministry.ca

M: P.O. Box 426 Carnduff, SK S0C 0S0

Application Form

First Name

Last Name

Email

Phone

Street Address

City

Region/State/Province

Postal / Zip code

Country

Birthday

Age:

Do you have provincial health coverage?

Region/State/Province

Health Number:

Marital Status

Do you have Children?

Yes

No

How many children?

Are you pregnant?

Yes

No

If yes, when is your due date?

Did you graduate high school?

Yes

No

Last grade completed?

Do you have any allergies?

Yes

No

Please list all allergies

Are you on any medications?

Yes

No

Please list all Medications:

Have you ever been arrested?

Yes

No

Do you have any court cases pending?

Yes

No

Please Select all the Substances You Have Experimented With:

Alcohol

Amphetamines (Uppers)

Barbituates (Downers)

Cocaine

Crack

Crystal Meth

Inhalants (Glue

Ecstasy

Hallucinogens (Acid

Heroin

Marijuana

Methamphetamines

Morphine

Opium

Prescription Medication

Tobacco

Pornography

Sex

None of the Above

Describe your lifestyle concerning drugs and alcohol during the past six months:

Select all that you have received as an official diagnosis:

Anxiety

ADD/ADHD

Bi-Polar

Borderline Personality Disorder

Depression

Dissociative Identity Disorder

OCD

Eating Disorder

PTSD

Schizophrenia

Sexual Addiction

Non of the Above

List Other

Have you ever attempted to harm yourself?

Yes

No

Have you ever attempted to commit suicide?

Yes

No

Have you ever recieved counseling?

Yes

No

Did you grow up in a Christian faith group?

Yes

No

What is your present relationship with Jesus Christ?

Non-existent

Distant

Somewhat Active

Active

Important

Significant

Defines Who I am

Why would you like to come to Choose Life Ministry?

I understand that Choose Life Ministry is a Christian faith based organization and recognize that this topic will guide the program. I agree to comply with the standards and co-operate with the staff of Choose Life Ministry. I understand that if I have not answered these questions truthfully or have knowingly withheld any information, it may be considered grounds for refusal to the program or discharge from the program due to noncompliance.

Your Signature

Select a date

Thank you! We’ll be in touch.

OFFICE HOURS:

Mon - Fri: 9am - 4pm

ADDRESS:

Choose Life Ministry

PO Box 426
Carnduff, SK S0C 0S0

T: 306.339.7793

E: office@chooselifeministry.ca

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