Executive Director: Vicki Wilkerson 865-388-9703

Executive Asst.Director: Thomas McGouey 865-684-9864

865-673-8427 Fax,

Application Date:_________________

Approximate Release Date:________________

CUT AND PASTE then Please fill out and/or circle the following information. Personal Information

Last Name

First Name

Middle Intl. I.D. # Present Street

Address
City State Zip

Home Telephone #________________________

Other Telephone #_____________________

Social Security #______-______-_________

D.O.B. _________________________

Place of Birth __________________________________ (Or circle) Unknown

Race (circle) White, Asian-American, American-Indian, Black, Other ____________________

Marital Status

Married Divorced Separated Widowed Other

Spouses Last Name

First Name

Middle Intl.

Spouse’s Street

Address

City State Zip

How long separated? ______________________

How long divorced? _____________

How long widowed ? ____________________

Cause of death ______________________

Has ex-spouse remarried? (Please circle) Yes No

Reason for separation or divorce:

How long were you married? ________________

Number of times___________________

Children

Please fill out if applicable, if not disregard.

Number of children with present spouse

Please list them: First Name Last

Name Relation

Age

________________________________________________________________ First Name Last

Name Relation

Age

________________________________________________________________

First Name Last Name

Relation ____________ Age

Number of children with ex-spouse ______

Please list them:

________________________________________________________________ First Name

Last Name

Relation_____________ Age

________________________________________________________________ First Name

Last Name

Relation______________ Age

________________________________________________________________ First Name

Last Name

Relation______________ Age

Do you have any contact with your children?

Yes No If not, please explain:

________________________________________________________________

________________________________________________________________

Family History

Father (circle) Living or Deceased

Name

________________________________________________________________ Father’s Street

City State Zip

Mother (circle) Living or Deceased

Name

________________________________________________________________ Mother’s Street

Address

City State Zip

Are your parents currently married? Yes or No

If known list reason(circle): Widowed Divorced

Other_________________________

Do you have brothers and sisters? __________

If so, how many brothers? _______

If so, how many sisters? _____

What was your position in the family? (youngest/middle/oldest)

_____________________ Do you have any family in town? Yes No

If so are you in touch with them? Yes No

Do you have comments in regards to this?

________________________________________ Education

High School Graduate? Yes or No

If not how many years did you attend?__________

College Graduate? Yes or No

If not how many years did you attend?_________

College Degree? Yes or No

Major/Minor_______________________________

Post Graduate Degree? Yes or No

What In? _________________________________

Trade school? Yes or No

Occupation? ______________________________

GED Yes or No

What Year?________________________________

Any other specialized training?

If so what? ______________________________________

Are you presently working in your field? Yes or No

________________________________________ Occupation/Job History

Employed? _________

Employer;______________________________________________

Work phone # ________________

Other phone # ________________

Work shift hours ______________ List your job history below: Co. Name Address Dates Co. Name Address Dates Co. Name Address Dates Co. Name Address Dates Are you presently working? Yes or No If not how long has it been since you last worked, and why? ______________________________________________________________ Service Experience Are You a veteran? Yes or No Branch of service? _________________________________ Time in service ______________ Date and type of discharge ____________________________ If other than honorable please explain; _______________________________________________ Are you retired from the service? Yes or No Retirement income amount? $____________ Do you have a service type disability? Yes or No Disability income $__________________ What type disability do you have? __________________________________________________ What type of work did you do in the service? _________________________________________ Health Information State of physical health? Excellent Good Fair Poor Declining If poor or declining, please explain: _________________________________________________ __________________________________________________ ______________ Do you have any allergies? If so please be specific. _____________________________________ ________________________________________________________________ List all major illnesses and/or operations and dates: _____________________________________ ________________________________________________________________ Are you handicapped in any way? Yes No Type of handicap ________________________ Do you have or ever have had Venereal Disease? If so, what kind and how was it treated? When? ________________________________________________________________ Have you ever been tested for the HIV virus? Yes or No Date/Location: __________________ Did you test positive? Yes or No Are you willing to be tested again? __________________ Have you ever been tested for T.B. ? Yes or No Date/Location: __________________ Did you test positive? Yes or No Are you willing to be tested again? __________________ Comments: ________________________________________________________________ List all medications you are presently taking and how long you have been taking them? ________________________________________________________________ Have you ever been in a psychiatric hospital? Yes or No Committed? Yes or No Were you committed voluntarily? If so, when and where :__________________________________ ________________________________________________________________ ________________________________________________________________ Have you ever attempted suicide? If so, when, where and why ? ________________________________________________________________ ________________________________________________________________ ____________________ Have you ever thought about suicide? _____ if so, when, where and why? ________________ ________________________________________________________________ Experiences with Others Have you ever had a severe emotional upset (death, divorce, loss of job, etc)? ___________ If so, explain: ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ Do you now have or have you ever had a problem with anger If so, explain: ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ Have you been in trouble in the past? _________ If so, what for? ________________________________________________________________ ____________________________________________________________________________________ Have you ever been in jail due to alcohol and/or drugs? If so, when and where?________________________________________________________________ Do you have any convictions? __________ Are you on probation or parole?___________________ If so, probation officer’s name: __________________________ Dependency Problems Do you have or have you ever had an addiction to drugs? If so, what kind. ___________________ ________________________________________________________________ What other drugs have you taken? _____________________________________________________ What age were you when you first began using? __________________________________________ When did you begin using regularly and why?____________________________________________ Why did you start using? _____________________________________________________________ ________________________________________________________________ Do you have or have you ever had a dependency on alcohol? If so, what kind do you drink? ________________________________________________________________ What age were you when you first started drinking? ___________ Regularly? _______________ Why did you start drinking? ___________________________________________________________ ____________________________________________________________________________________ How often do you drink? ______________ Do you drink in the morning?___________________ When was the first time you were drunk? _______________________________________________ Have you ever had blackouts, D.T.’s, etc.? (Explain) _______________________________________ ________________________________________________________________ ____________________ When was your first blackout (what age)? ___________ Why do you want to stop drinking? _____ ________________________________________________________________ ____________________ Have you ever been in any treatment for drugs and/or alcohol? _____________________________ How many times have you been in treatment? When and where? ___________________________ ________________________________________________________________ ________________________________________________________________ Do you attend “help” meetings?__________ If so where? __________________________________ Do you have a home group? ________ How much continuous sobriety/clean time do you have? ____________ Does your spouse have an addiction problem? ______ If so, has he/she ever received treatment? _______ When? __________________ Is spouse sober now? _____ How long?_____ If not, why?(explain)________________________________________________________________ Insurance Information Do you have hospital insurance? ______ With whom? __________ Ins. No. _________________ Medicare No. _______________ Medicaid No. _______________ Other ____________________ Will you sign a release of information form so that we may write for helpful medical or other information if necessary? _____________________________________________________________ Other Information Do you own a home? Yes or No Rent? Yes or No Other _______________ Do you own property? Yes or No Car? Yes or No Make/Model ____________ Do you have a driver’s license? Yes or No License No. _______________ State _______ Religious Background Do you attend church? Yes or No Regularly? Yes or No Did you attend church as a child? Yes or No Age started: _________ Do you have a church you attend now? Yes or No Name: _____________________________ When was the last time you attended? _____________ Pastor’s Name: ______________________ Does your spouse attend church? Yes or No Regularly? Yes or No Are you a “Born again Christian” Yes or No? Have you been baptized? Yes or No Do you participate in anything other than a worship service? Yes or No __________________ If so what kind?________________________________________________________________ What denomination are you most comfortable with? _____________________________________ Are you involved with any other type of Christian service? ________________________________ If so, what? ________________________________________________________________ ________________________________________________________________ ___________________ Would you consider attending other churches? __________________________________________ Do you pray? _________ How often? _____________________________________________ Would you like to grow spiritually if you join the Peace at Last program? ____________________ Do you read the bible regularly? If so, how often? ________________________________________ Do you know the spiritual gifts the lord has blessed you with? ______________________________ ________________________________________________________________ Do you know what the ‘Great commission’ is and how it relates to you? Yes or No Would you like some information in regards to this? Yes or No Please describe your spiritual journey thus far in life. ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ Regarding Information and Books that Inform and Help Do you read ‘Help’ books? Yes or No w ould you like to? Yes or No What books do you read, if you read? ___________________________________________________ Would you be comfortable studying on a regular basis if you decided to come here? ____________ List some problems you would like to get help with? ________________________________________________________________ Emergency Information Name(s) of person(s) authorized to act for you in the event of an emergency: 1. First name Last name Relation Phone numbers 2. First name Last name Relation Phone numbers I (your name)______________________, understand that the Peace at Last Ministries can only guide me in the right direction; that I am responsible for progress in my life and that God helps those that help themselves. I (circle) will/will not attend an accountability group.