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Begin your journey to freedom and healing

Personal Information

First Name *

Last Name *

Email *

Phone *

Present Address *

City

Postal Code

Country

Birthday *

How did you hear about us?

Marital Status

Do you have children?

Yes

Health Information

Do you have allergies?

Yes

Are you on any medications?

Yes

Substance & Diagnosis History

Please select all 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

None of the Above

Drug of Choice

Describe your lifestyle concerning drugs and alcohol the past 6 months

Mental Health History

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

Have you ever received counselling?

Yes

Have you ever attempted suicide?

Yes

Have you ever attempted to harm yourself?

Yes

Faith & Goals

Did you grow up in a Christian Faith group?

Yes

What is your present relationship with Jesus Christ?

Why would you like to come to Choose Life Ministry?

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

Agreement

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.

Date *

Need Help?

Office Hours: Mon-Thurs 9am-4pm

306-339-7793

admin@chooselifeministry.ca

PO Box 426, Carnduff, SK S0C 0S0

Helping individuals find hope, healing, and transformation through faith-based programs and community support.

Homestead for Hope

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