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Mental Health Status & Cognitive Concerns

Do you have a diagnosed mental health disorder?
If yes, please select any diagnosed mental health disorders that apply to you.
Do you have concerns about any potential undiagnosed mental health disorders?
Do you have a history of suicide attempts?
Do you have a history of self harm?

Physical Health Information

Are you currently taking any medications?
Will you have a 1 - 2 week supply of your medications upon arrival?
Do you have any medical dietary restrictions or preferences? (Celiac, allergies, etc.)
Do you have any physical injuries or issues that limit your mobility?
Do you require assistance with physical hygiene?
Do you have any diagnosed medical conditions?
Do you have approved MSP (Medical Service Plan) coverage?

Legal History

Are you currently under any legal supervision? (probation officer, bail supervisor, etc.)
Do you have a history of verbal aggression towards others?
Do you have a history of physical aggression towards others?
Do you have a history of weapon use?

Emergency Information


Emergency contact's information.

In the case that you have to leave the program early where will you go and how will you get there?

Clean Time requirement

Please click "SUBMIT" and your application is complete.

Please make sure to call us at (250) 785-1008 to ensure your application has been received.

ADMISSION REQUEST FORM

Personal Information

Date
Month
Day
Year
Date of Birth. (You must be 19 years of age or older)
Month
Day
Year
Would you like to see change in your life?
Are you willing to commit to stay for the full length of the 6 month program?

Current Housing

What is your current living situation?

Addiction History & Information

Do you struggle with addiction(s)?
Please select all that apply to you:

What we offer as a part of our 6-month program:

  • Inner Healing (dealing with unresolved emotional pain - foundation of the program)

  • Housing

  • Employment Readiness Training

  • Life-Skills Development Classes

  • Personal Development

  • Spiritual Mentorship

Program Cost & Personal Income

$1800 a month + a one-time $350 damage deposit and $100 supplies fee. This excludes items such as personal groceries, transportation including cabs and bus fares, cigarettes and vapes, toiletries, personal items, etc.


List your primary source(s) of income and the amount received per month. Answer all that apply.

Do you have any outstanding debts?
Do you have a financial aid worker?
Will you have approved funding in place to pay for the program?

Family/Social Network

Do you have any children?
Is child protection currently involved with the family?

Please click "SUBMIT" and continue filling out the next form.

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©2023 by Rising Above Ministries FSJ

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