Tabitha Ministry Application for Enrollment
Please answer all questions honestly and completely. Someone from Tabitha Ministry will be in touch soon to discuss your application. To check on the status of an application, call 336-441-8003 or email tabithaministryncinfo@gmail.com. 
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Full Name *
Phone Number *
Address *
Age *
Birthdate *
MM
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DD
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YYYY
Race *
Height *
Weight *
Were you born female? *
Driver's License, including state & expiration date *
SS Number *
Hair Color *
Eye Color *
Emergency Contact Name *
Relationship to You *
Home phone *
Cell phone *
Work phone *
Address *
Check if any of these situations apply.
Did you graduate high school? If yes, share graduation year. If no, last grade completed. *
My ability to read is *
Are you interested in obtaining a GED Certificate? *
Other Degrees or Diplomas *
Special abilities or training *
List any learning disabilities *
Provide 5 years of employment history: Employer, Job Title, & # years worked. *
Marital Status *
If you are married, provide spouse's full name, phone, & address.
If applicable, describe any problems or concerns related with your spouse or boyfriend.
Provide the names, ages, and birthdates of all children. *
Do you currently have custody? If yes, please explain. *
Describe any positive or negative aspects of your relationship with your children. *
Were you raised by your parents? If no, please explain. *
Have you experienced any deaths in your family in the past year? If yes, explain who and when. *
Describe your relationship with your parents. *
Check all that apply *
Required
Are you currently in a romantic relationship? *
Describe any problems or concerns in any of your recent relationships. *
Have you been held against your will or put in controlling/abusive situations where basic freedoms and necessary functions were withheld?  
 *
Have you been drugged to force compliance against your will?  
 *
Have you been forced to work without being allowed to keep your wages?  
 *
Have you been forced to have sex with someone you did not want to be with?  
 *
Do you have any restraining orders? If yes, against whom and why? *
Have you ever been incarcerated? *
If you have a probation officer, share name, phone #, address & how often you report.
Do you have pending criminal charges? *
Do you have any pending civil lawsuits or divorce? *
Are you required to register as a sex offender?  *
Provide attorney/public defender's name, address, and phone, if applicable.
Provide social worker's name, address, and phone, if applicable.
 *
Rate your health on a scale of 1 (poor) to 10 (excellent). *
Poor
Excellent
Recent weight changes? If yes, specify # of lbs lost or gains and how long. *
Share date & result of last medical exam. *
Share name, address, & phone number of physician & medical facility. *
List all medication you are presently taking, including reason, prescriber, address, & phone #. *
Share all drug allergies. *
List all present or past allergies, illnesses, injuries or handicaps.  *
Share any physical limitations. *
Can you easily climb stairs carrying 20 lb? *
Share any dietary restrictions. *
Have you had past pregnancies, current pregnancy, and/or past abortions? Explain yes answers. *
Have you been sexually molested abused, or raped? At what age? Explain what happened. *
Check if you have ever had any problems or been diagnosed with any of these conditions. *
Required
Explain each condition you checked above. *
Identify all substances you have used in the past or present. *
Required
For each substance you have used, share age started, date last used, and typical amount. *
What is your drug of choice? *
How did you support your substance use? *
Required
List other programs you have been in, including Tabitha Ministry, if applicable. Include dates and reason(s) for termination. *
Anything else Tabitha Ministry should know about your alcohol/drug history? *
Check any of the following words that best describe you. *
Required
What occurred in your life to cause you to come to Tabitha Ministry? *
Past suicide attempt? If yes, why? *
Ever prescribed a mental health medication not already listed? If yes, explain reason prescribed, medication, and dosage. *
  Ever had a “bad trip” that resulted in a major mental break?  
 *
Ever required Narcan or other method to be revived after heart had stopped? If yes, how many times?   
 *
History of psychological or psychiatric care of any kind? If yes, share where treated; dates/length; therapy type (group, psychiatric, or hospitalization); and outcome. *
Have you ever had any problems or been diagnosed with any of these conditions? *
Required
Explain any condition marked above. *
Is there any other information Tabitha Ministry should know? *
Do you believe in God? *
What do you call God? *
What are your spiritual beliefs? *
Have you ever been involved in a cult? If yes, please explain. *
Did you family attend church/religious services when you were a child? *
Which religion/denomination if yes?
Describe any recent changes in your spiritual life. *
List three life goals. *
What is something people mistakenly think about you? Why is this assumption wrong? *
Please read the Tabitha Resident Expectations posted on the home page of the website. Do you agree to all of these expectations? *
Please read the Legal Release that included at the end of the PDF application posted on the home page of the website. Do you agree to all terms?  *
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