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Residential Program Intake Form

Residential Program Intake Formnewlifemission2023-08-24T10:37:47-04:00

Need help? Call: 1-321-505-8605 (please allow 24-48 hours for return call)

Our program is a residential program that lasts anywhere from six months to two years.

To be eligible you must be:

A single adult woman with legal custody of a child or children

Willing to relocate within Brevard County and commit to a long term program

Willing to work under daily supervision of case manager and accept provided counseling

Willing and able to work, volunteer or participate in job training 40 hours a week

Willing to develop skills in parenting and money, household and time management

Hear from four moms whose lives were changed by the New Life Mission program.

Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Phone*
Email*
What agency or person referred you to New Life Mission?*
How many children do you have (if any)?*
What are their ages and dates of birth (if applicable)?*
Do you currently receive child support?*
- Yes
- No
Where are you currently living?*
Have you ever lived in transitional housing?*
- Yes
- No
Are you currently working?*
- Yes
- No
If so, what do you do for work? If not, when was the last time you were employed?*
Do you have a GED or High School Diploma?*
- GED
- High School
- Neither
Do you have post high school education / certifications?*
- Yes
- No
If you have certifications, what are they?*
Are you single, married, or separated?*
- Single
- Married
- Separated
Are you pregnant?*
- Yes
- No
Are you a Christian? (Not necessary for acceptance)*
- Yes
- No
Do you attend or have you ever attended a local church? If yes, which church do you attend?*
Are you disabled? Receiving SSI?*
Are you a Brevard County Resident?*
- Yes
- No
Are you a US citizen?*
- Yes
- No
Do you have any legal matters, arrests, convictions currently or in your past? If so, explain.*
Are you currently in a domestic violence situation?*
Have you ever been in a domestic violence situation?*
Are you currently , or have you ever struggled with an addiction?*
- Currently Struggling
- History of addiction
- No addiction history
If you checked currently struggling or history of addiction above, have your received treatment? When? Where?*
Do you have a restraining order or no contact order?*
- Restraining Order
- No Contact Order
- Neither
Have you ever had an open DCF case?*
- Yes
- No
Do you or you children have any medical issues?*
Are you currently taking any medication? If so, please explain.*
Are you currently using any illegal or controlled substances?*
Are you a smoker?*
- Yes
- No
If yes, are you willing to quit?
- Yes
- No
Do you currently have a Driver's License?*
Do you have a car?*
- Yes
- No
Do you have a car payment?*
- Yes
- No
Do you have current car insurance?*
- Yes
- No
Why do you think you need this program?*
What are your goals in this program?*
Phone
This field is for validation purposes and should be left unchanged.

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321-480-9100 | PO Box 362203, Melbourne, FL 32936 | Charity ID# 26-1686406

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