Application

Applicant's Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Primary Phone Number *

Country

(###)

###

####

Secondary Phone Number

Country

(###)

###

####

Consent to Contact *

I consent to be contacted by Discipleship 33 via SMS, email, or phone using the information I provided for the purposes of reviewing my application.

Emergency Contact Name *

First Name

Last Name

Emergency Contact Phone Number *

Country

(###)

###

####

Drug(s) of Choice *

Amphetamines

Barbiturates

Benzodiazepines

Buprenorphine

Cocaine

Ecstasy (MDMA)

Methadone

Methamphetamine

Morphine

Oxy

PCP

THC

Alcohol

Bath Salts

K2

Kratom

Heroin

Opiates

Ketamine

TCA

Fentanyl

Inhalants

Nicotine

Psychedelics

Other

Are you currently using any prescription medications? *

Yes

No

Are you participating in or about to enter any drug replacement program? *

Yes

No

What is your Sober or Clean date? *

MM

DD

YYYY

Do you have a Sponsor? *

Yes

No

Do you have a Case Manager? *

Yes

No

Do you have a Recovery Coach? *

Yes

No

Do you have any immediate needs such as clothing or toiletries? *

Yes

No

Do you need assistance with any self-help, support group and/or networks within the local community? *

Yes

No

Do you need help to renew any forms of identification? *

Yes

No

Do you need assistance with any food programs? *

Yes

No

Were you referred to Discipleship 33? *

Yes

No