Freedom Place UC Application

Ready to begin your journey to freedom?

Complete our online application to take the first step toward Christ-centered recovery and restoration.
Our team will review your submission and reach out to walk with you through the next steps — you're not alone.

“Come to me, all you who are weary and burdened, and I will give you rest.” — Matthew 11:28 (NIV)

This field is for validation purposes and should be left unchanged.

General

Name(Required)
Current Address(Required)
Please specify

Personal

Date of Birth(Required)
Gender at Birth(Required)
(optional)
Are you an American citizen?(Required)

Education

Do you have your GED?

Military Service

Have you served in any branch of the military?(Required)
If yes, type of discharge?

Marital Status

Are you?
Do yu have any minor children?

Drug History

Have you experimented with drugs or alcohol?(Required)

Legal Status

Current legal status
Any violent convictions?
e.g. Robbery, kidnapping, etc.
If not in jail, are you on probation or parole?

Financial Status

Are you receiving welfare, unemployment, disability, workman's comp, alimony, or other income?
Do you have any outstanding debt, court fines, or child support obligations?

Health Status

Do you currently have health insurance?
Have you been hospitalized for any mental health issues?
Are you receiving treatment currently?
Have you attempted suicide?
Are you having thoughts of suicide currently?

Physical Health

Do you have HIV, Hepatitis or TB?
Are you currently on any medications?
Do you have Epilepsy, Seizures, Diabetes?
Do you have any allergies?
(e.g.classes, shores, transport)
Have you been hospitalized in the past 12 months?

Health Care Provider

Name
Address
MM slash DD slash YYYY
MM slash DD slash YYYY
Are you willing to release your medical records to Freedom Place?
Do you use nicotine? This includes vaping.

Spiritual History

Do you believe in God?
Have you committed your life to God?
Prior to incarceration, did you attend church?
I certify that the answers are truthful to the best of my ability.
Clear Signature