Initial Application - This is Living
Would you like to apply online or be contacted to ask questions about our program? Please fill out the form! The applicants who are admitted to our program are first interviewed by the director. The director will go over rules and regulations and make a determination of an applicant's readiness to attend TILM's 12 month reentry program. Please complete all information below and our team will be in touch for an initial phone interview. Thank you for your interest in our program.
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Email *
First & Last Name *
Date of Birth
Phone number *
Current Address: Street # & Name, City, State Zip
Emergency Family member:  contact name, number,  & relationship to you *
Incarceration Information
TDOC # *
Do you have any current or pending charges? If so what are they, which county/ state are they in, and when are you set to appear in court for each charge? *
How long have you been incarcerated, if applicable?
Parole Hearing Date
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Have you ever been convicted of a sex offense, violent crime, or arson? *
How many times have you been in jail?
How many times have you been in prison?
Do you have any felony convictions? Please list charge, date, location & sentence received. *
Name, phone number, location, and email address of probation/ parole officer
Identification Information
Do you have a copy of your birth certificate
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Do you have a copy of your social security card?
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Do you have a copy of your state ID/ Driver's License
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What state were you born in?
Medical History & Information
Please list all medications/ reason for taking/ dosage and times per day. *
Date each was prescribed
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Approx. Medication Cost?
Have you been tested for any of the following?
 If so, please list the test date & the results.
Have you ever been treated for any of these?
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If treated, please explain:
Please list all known allergies:
Do you have any chronic medical conditions? *
If yes, please list & explain:
Have you ever had or needed surgery for an existing medical condition?
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Please list the dates of the surgery if you answered yes:
Are you physically able to participate in full time employment, chores, yardwork, & work duties? *
Are you pregnant or could possibly be pregnant?
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Have you ever had an abortion or a miscarriage?
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Have you ever be hospitalized (aside from having children)? (Mental or physical)
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If so, when was your last hospitalization and what were you treated for?
Do you have a mental health diagnosis?
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What age were you diagnosed and what is the diagnosis?
Have you sought treatment for mental health before? (Please list treatment facility as well)
Have you ever tried to commit suicide?
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If so, when?
Have you ever tried to kill or hurt someone else?
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Please list date of incident
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Have you ever harmed yourself?
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If so, when
Has harming yourself become a life controlling issue?
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Trauma History
Do you have a history of trauma?
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Emotional/ Mental Trauma. Please describe
Physical Trauma. Please describe
Sexual Trauma. Please describe
Have you ever received counseling for these issues?
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Sexual Orientation?
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Substance Abuse History
Has addiction use been prevalent in your family? Please list which family members & which addictions.
Are you currently dependent on/or take drugs or alcohol?
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At what age did you begin using drugs?
When did you last use?
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What was you drug(s) of choice?
How often did you use them?
At what age did you begin using alcohol?
When did you last use alcohol?
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Has incarceration been prevalent in your family? Which family members?
Have you tried to stop using drugs prior to incarceration?
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Did it work?
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If not, what do you believe caused the relapse?
If it did work, how many consecutive days without use?
Have you ever been in treatment or a recovery program?
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If yes, please list when, where, and what type. Did you complete them? *
What have been the consequences of your drug use?
Spiritual History
Have you ever had a relationship with God, Jesus, & Holy Spirit? How would you describe it?
Have you attended church?
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How often did you attend? & when was the last time you attended?
Do you have a church preference?
Have you ever been involved in religious practices, such as: sorcery, wiccan, voodoo, etc?
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Family History
Marital Status *
Spouse's name
Length of relationship:
How is your relationship with your spouse?
Does your significant other have a drug or alcohol use problem?
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Would your spouse be helpful to your sobriety?
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If you are not married, are you willing to give up your relationship with your significant other while in our program? *
Do you have children
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If you have children, what are their names, location & in who's care?
Who currently has custody of your children? Please list names, relationship to children and address.
How is your relationship with the care givers of your children?
Do you currently have any cases with DCS? If so, what county?
How were you disciplined as a child?
Are your parents living and are they still together? Please describe.
Please explain your relationship with your parents
Do you know of anyone that would want to know your whereabouts in order to harm you in any way? *
If yes, please explain
Are you currently working?
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Are you willing to stop working while at TILM?
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Are you willing to quit  smoking or vaping?
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Referred by
May we contact them
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Why do think you want to attend TILM?
Is there anything else you believe we need to know prior to your interview or review for acceptance into our program?
General Program Rules Agreement
The following are several of the basic rules for TILM. You will be provided with a complete policy handbook upon admittance, if accepted into our program. The TILM program is offering a life changing opportunity to participants for a minimum of 12 months and maximum of 18 months.

By turning in this application you are agreeing to the following:

I UNDERSTAND:
TILM is a christian growth center, and I agree to be included in biblical teaching and Christian forms of activities.
My main purpose for being in the program is to learn a new way of life, not just to escape my current situation or consequences.
My main goal is to complete the 12 month TILM program and become a productive member of my family, church, and community.

I always agree to take personal responsibility for my own attitude and behavior. I understand that what program authority calls incorrect or improper behavior, and/or a bad attitude will be addressed and may be disciplined if necessary. I will agree to do the disciplinary action or project with an improved attitude.

I WILL NOT:
Possess or use drugs at any time (this includes store bought drugs)
Smoke, vape, or have cigarettes in my possession (any form of nicotine)
Curse or use off-color expressions or bodily gestures or names
Talk about street life, drugs, or glamorize my past or my wrong doings.
Horseplay, wrestly, or engage in inappropriate bodily contact.
Put my hands on other participants, staff, or volunteers in any unacceptable fashion.
Become part of or help create "cliques" in the home
Go outside the house/ grounds without staff permission.
Bring any weapons
Bring any books, CDs, music, radio ect, that is not pre-approved by the staff
Use or possess any electronic devices such as cell phones, tablets, computer/ laptop, or schedulers

I AGREE:
To the staff screening and reading my mail prior to being sent or after arrival of incoming mail
To only write two 3 page letters per week to members of my immediate family only - I will not write to boyfriend/ fiance.
To not use anyone or any means to communicate with anyone outside of my immediate family.
To my phone calls, cell phone, email, visits etc to be monitored by staff.

I AGREE:

To participate in all scheduled activities chosen by the staff. This may include class, devotionals, church, work, hobbies, reading, recreation, chores, and more. I will do what is required to execute actions steps and reach desired outcomes.
I will do my utmost to include myself in groups in order to change my behaviors, heal from my past, and learn new skills.
To conduct myself in a Christlike manner and will not do anything in public that will call attention to myself or reflect badly upon TILM or our group.
I will give healthy feedback to my peers in TILM during groups and not condemn nor persecute any other participant. I will share experience, strength, and hope. I will share how I went through a given situation now what another should do.

I UNDERSTAND:
That I am expected to be prepared, in place, and on time for all my scheduled activities 24/hours a day. I also understand that any tardiness, unpreparedness, and other forms of carelessness will result in disciplinary action.
That my room must always be kept in a neat and orderly manner. I agree to work with my roommates to keep it clean and in shape for inspection.
That staff may at any time confiscate excessive possession, or possessions left in common/ group areas
There will be a dress code that is modest and devoid of slurs, foul language, etc.
There will be a hygiene code: hair combed, showers daily, laundry/ chores daily.
That disciplinary action may include: extra duty, loss of privileges, suspension of phone calls/ passes, or dismissal.

I hereby certify that all the above information is correct to my knowledge. I agree to the terms of This is Living Ministries and am willing to commit to my new life. I understand the views of this organization, and I am ready to begin my new journey into freedom and sobriety in a Christian atmosphere. I have read these rules and my signature below indicates that I have a good understanding of them, and that I am willing to commit myself to these agreements, rules, and guidelines and to the more detailed handbook agreements, I will receive upon entrance into TILM Re-entry home.
Type your name below if you agree with the above Program Rules/ Guidelines statement *
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