APPLY to Our Program | Choose Life Ministry

top of page

HOME
UPCOMING INTENSIVES
NEWSLETTER
APPLY to Our Program
DONATE
ABOUT
GET INVOLVED
BOUTIQUES
CONTACT
More

Use tab to navigate through the menu items.

Follow Us!

Apply Now

First name*

Last name*

Email*

Phone*

Address

Country/Region*

Address*

City*

Zip / Postal code*

PRESENT Address*

Birthday*

Year

Month

Day

How did you hear about us?*

Parents

Friend

Internet

Church

Other

What is your marital status?*

Single

Married

Divorced

Separated

Widowed

Common Law

Do you have children?*

Yes

No

Do you have allergies?*

Yes

No

If yes, please list all allergies

Are you on any medications?*

Yes

No

If yes, please list all medications

Please list all the substances you have experimented with:*

Alcohol

Amphetamines (Uppers)

Barbiturates (Downers)

Cocaine

Crack

Crystal Meth

Inhalants (Glue)

Ecstasy

Hallucinogens (Acid)

Heroin

Marijuana

Methamphetamines

Morphine

Opium

Prescription Medication

Tobacco

Pornography

Sex

Non of the Above

Other ______________________

Drug of Choice

Describe your lifestyle concerning drugs and alcohol the past 6 months *

Select all 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

None of the Above

Other _____________________________

Have you ever received counselling?*

Yes

No

Have you ever attempted suicide?*

Yes

No

Have you ever attempted to harm yourself?*

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 Ministey?*

What would you like to see happen in your life while at the Choose Life home?*

I understand the 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.

Signature*

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

Date*

Year

Month

Day

OFFICE HOURS:

Mon - Thurs: 9am - 4pm

ADDRESS:

Choose Life Ministry

PO Box 426
Carnduff, SK S0C 0S0

T: 306.339.7793

E: admin@chooselifeministry.ca

GET OUR NEWSLETTER!

Subscribe

© 2022 by Choose Life Ministry

bottom of page