SWB Application
Please complete this application in it's entirety. Once submitted, your application will be reviewed by the Still Waters Brevard Program Coordinator. After review, you will be contacted by phone and/or email to discuss the next steps of the application process. 

Wholeness To Freedom Ministries Inc./Still Waters Brevard      
1619 Ferndale Ave. Melbourne, FL 32935       
Office Phone: (321) 425-5494
Email: swb@wholenesstofreedom.org
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Application Date *
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Referral Name/Program
First Name
Last Name
DOB
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YYYY
Current Address/Location *
Zipcode
Name of Shelter/Program (type NA if not applicable)
Last Permanent Address
Zipcode
Phone Number
Email
If you do NOT have a phone, how can we reach you? (list a name and phone number)
Marital Status
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Are you currently experiencing domestic violence?
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If you answered YES to the question above, please explain below.
Have you recently experienced domestic violence?
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If you answered YES to the question above, please explain below.
 Are you in fear for yourself/children? 
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If you answered YES to the question above, please explain below.
Education (Please select all that apply)
Race
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Veteran
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Funding Sources (please select all that apply)
Employment
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Financial (check any that you currently have)
Residential (check all that apply)
Legal (please check all that apply)
Children
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If you have minor children, please list how many children you have and list each of their ages.
Do you have a Child Custody Agreement?
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Help Us Get to Know You Better.

Your story is important to us, and we recognize it’s what has shaped and brought you to the present moment. It’s what helps us understand why we do the things we do, and what we want to be different in our futures. 

Please share your story and what has brought you to the present.
What is happening in your life physically and emotionally?
What are some struggles or patterns you are looking to overcome?
Please share where you are in your faith/religion at this time.
What are your future goals?
What makes Still Waters Brevard the best decision for you right now?
Please review the Still Waters Brevard program information/eligibility requirements  by clicking the link below: 
Acknowledgement *
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