Life Change Recovery Program

The Life-Change Recovery Program is for the sole purpose of understanding the causes, frequency, and effects of our choices in order to restore individuals into changed and healthy people. The following questions are very personal, so please answer carefully and honestly. The information you provide will be held in the strictest confidence and will not be shared outside of VRM or the court system, without your permission.

To print and complete this application instead, click HERE.

If completed by friend or family member, please provide your name:

First Name

Last Name

Applicant Personal Information

Name:

First Name

Last Name

Contact Number:

(###)

###

####

Email:

Gender:

Current Address:

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Social Security #:

If applicant does not possess a social security number, please note with "N/A"

Date of Birth:

YYYY

Age:

Where were you born?

Height:

Weight:

Eye Color:

Hair Color:

Any identifying marks?

Birthmarks, tattoos, etc.

Emergency Contact Person and Relationship:

Include full name, relation to person, and contact information (address and phone number)

Are you receiving any government benefits?

Do you have a source of income?

Are you a US citizen?

Ethnicity:

Religious Preference:

Do you know anyone currently enrolled in a VRM Academy? If so, who?

Education:

Highest Grade Level Completed:

Did you earn a High School Diploma or G.E.D.?

Vocational Training Received:

Military Service/Veteran

Have you served in the military?

Employment/Work History

What type(s) of work have you done?

Is there anything preventing you from working?

Personal Evaluation

What issues are you currently dealing with in your life?

Check all that apply

Addiction

Abuse

Hurt

Hopelessness

Homelessness

Other

Have you ever tried to get help for these issues?

Family

Marital Status

Do you have children?

Do you have siblings?

Are your parents still living?

Does anyone in your family have addiction history?

Health

Have you ever been hospitalized?

Have you ever been diagnosed with an emotional/mental condition?

Have you ever attempted suicide?

Are you currently on any medications?

Are you currently under a doctor's care?

Medical Coverage:

Legal History

Have you ever been arrested?

Are you court-ordered to complete this academy?

Have you been convicted of a sexual offense?

Religious/Church History

Have you ever or do you currently attend church?

Do you believe in God?

Our Life Change Recovery Program is a Christ-centered, faith based program. Are you willing to keep an open mind as you go through it?

Supplemental Questionaire

Please answer each question as completely as possible. Your answers should appear in essay format and be as detailed as possible to enable our team to properly process this application.

What do you hope to achieve with respect to your future through this Academy?

When you look in the mirror, what do you see?

Describe your personality:

What are your core beliefs about life, the world, religion, and relationships?

Please answer each area separately.

What are your strengths? What are you good at?

Life Change Recovery Program

Visalia Rescue Mission

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