Life Change Questionnaire
Application for Gateway Program
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Name *
Today's date
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Birthdate
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Email
Phone number *
Backup contact name *
Backup contact email/phone number *
Gender *
Marital status *
Required
Do you struggle with addiction? *
What do you struggle with?   *
When did you start? *
When was the last time you used? *
Do you want to change? *
What are you willing to sacrifice for change? *
What do you want to change? *
What would your life look like if you achieved the change you desire? *
Have you tried to change in the past? *
Have you attempted or completed any programs in the past?   *
If so, name the program, dates of attendance, and location?  
Reason for leaving (if applicable)
How long till you relapsed after leaving (if applicable)
What did you learn or complete in the program?
Describe your relationship with God.   *
What is your current health condition?   *
Do you have any ongoing treatments or upcoming surgeries/procedures? *
Do you have any work restrictions or need to be evaluated for restrictions? *
Do you have any mental health issues and/or are you working with any mental health agencies? *
Please list all medications you are prescribed. Please include the following information (medication, dosage, how long have you been taking it) *
Do you have State Benefits (Health/Dental Insurance, Bridge card, etc.) Please list *
Do you have a current Driver's License or State ID *
Are you working with or required to work with Friend of the Court (FOC)? *
If yes, please describe your FOC obligations
Are you working with any other outside agencies (Good Sam, IOP, OAR, 70X7, etc.)
Do you have any income/ongoing income (SSI, SSDI, Disability, Retirement, Unemployment, etc.)? *
If yes, please list income and monthly amount. *
If you have ongoing income are you opposed to providing a ministry fee? *
Are there any charges pending against you currently?   *
If yes, please explain the charges pending against you.  
Any court dates pending currently? *
If so, when?
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Did you ever have a CSC conviction? *
Do you object to us notifying law enforcement that you are here? *
What is your current legal status? *
Required
If you are on probation, who is the probation officer?
Please list the names and ages of children that are in your care and will be living with you for the duration of the program.  
Please list the name and ages of  your children that are NOT currently in your care.
Do you currently have an open CPS case? *
HRM Gateway Program reserves the right to contact CPS when children are in your care.  Are you opposed to this?   *
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