Skip to content
Hours : Mon-Friday 8-5
(931) 400-0316
Toggle Navigation
About Us
FAQ
Get Involved
Student Sponsorship
Volunteers
Business Partners
Church Visits
Give Now
Enterprise
Testimonials
Contact
Apply
Toggle Navigation
About Us
FAQ
Get Involved
Student Sponsorship
Volunteers
Business Partners
Church Visits
Give Now
Enterprise
Testimonials
Contact
Apply
Apply
Apply
Apply to attend Next Step for Life
Apply
shane@rolandadvertising.com
2024-04-25T15:02:46+00:00
Next Step for Life Pre-Screen Application
Today's Date
*
Full Name (First, Middle, Last)
*
Birth Date
*
Address
City, State
Zip Code
*
Phone
*
Where are you living at this moment?
*
Referred by
May we contact them?
Have you ever had a relationship with God? *
Yes
No
Are you willing to work towards developing a relationship with God? *
Yes
No
Are you currently employed?
Yes
No
If yes, how long have you been there?
Are you willing to cease working in order to be in the NSL program?
Yes
No
Do you have any children?
Yes
No
If you answered yes to the above, how many?
What are their ages?
Where are your children/who has custody?
Are you currently in an intimate/committed relationship?
Yes
No
If yes, what is their name?
Will you agree to disconnect from any romantic/intimate relationships (outside of marriage) for 12 to 18 months?
Yes
No
Do you have a cell phone?
Yes
No
Will you agree to turn it in and not to have a phone while in NSL?
Residents of the Next Step for Life program are not allowed to have cell phones.
Yes
No
Do you currently use or are you dependent on drugs or alcohol?
Yes
No
Are you willing to go to inpatient treatment?
Yes
No
Do you smoke cigarettes?
Yes
No
Are you willing to quit smoking?
Yes
No
If incarcerated, how long have you been detained?
Do you have charges pending?
Yes
No
If yes, what are the charges? Do you have any upcoming court dates?
Are you on probation/parole?
Yes
No
If yes, what is your probation officer's name?
Probation company's name and phone number:
Have you been convicted or revoked to serve?
Yes
No
If yes, how long is your sentence?
How much time has been built into your sentence?
Where are you currently being housed?
Address of facility (Street, City, State, Zip)
Do you have any health issues?
Yes
No
If yes, please specify:
Are you currently prescribed to any medications (this includes psych meds as well)?
Yes
No
We must have a release of information (ROI) to communicate with your health care and/or mental health providers; are you willing to sign one?
Yes
No
When was your last physical
*
What is the condition of your teeth?
*
What is the condition of your eyes?
*
Do you have a mental health diagnosis?
Yes
No
If yes, what age were you diagnosed and what is the diagnosis?
Females: Are you pregnant?
Yes
No
I don't know
I understand there is a $500 non-refundable intake fee at the time of entry into the NSL program and that monthly fees will be discussed at the time of the interview.
Yes
No
I understand the NSL program is a drug/alcohol/tobacco-free program and that I will be subject to random drug/alcohol/nicotine testing.
Yes
No
Do you have any active or pending warrants you are aware of?
Yes
No
Submit
Page load link
Go to Top
