FREEDOM CITY MINISTRIES

ABBA’S HOUSE – APPLICATION FORM –

PLEASE READ BEFORE CONTINUING
We are designed to make Disciples of Christ, and our recovery is centered on the principles and disciplines
found in the Bible. We need our applicants to be willing to surrender and give 100%.If you cannot handle being
without a relationship or have a problem with someone getting in your business, you need to stop filling out this
application. Remember your way does not work, so you must be willing to allow us to help you develop a new
way of living. We have never had anyone surrender to the structure of the program and fail! Those who fail are
those who refuse to surrender and try to hold onto the old way of living.

Basic Information: *Include Photocopy of: SS Card/Picture ID/Birth Certificate Date ____________
Full Name
(Last)_______________________(F)_______________________(M)____________Age:______
Street Address: ______________________________________ Apartment/Unit #__________
City________________________________________ State __________ ZIP Code__________
Phone: _______________________ (Cell) (Home) (Other) Exp.__________________
Social Security No: __________________________ Date of Birth _____/______/___________
City/State/Country of Birth_______________________________________________________
ID/Driver’s L. Number______________________________ Exp.____________ State_________
Gender______ Marital Status M. S. D. W. S.P. Spouse Name__________________
Emergency Contact_______________________________ Phone # _______________________
Name & Age of Children_________________________________________________________
Explain your relationship w/ your children, and their mother or (guardian)._______________
_____________________________________________________________________________
_____________________________________________________________________________
Immediate Family Members ______________________________________________________
_____________________________________________________________________________

Are you a sex offender? YES NO

How did you hear about Abba’s House (and or) Freedom City Ministries?
G Friend Family Pastor Parole Officer Drug Court Other_________________

Explain: your reason to come to Abba’s House and what you’re hoping to achieve?
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
______________________________________________________(*Attach separate sheet if needed)

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FREEDOM CITY MINISTRIES
ABBA’S HOUSE – APPLICATION FORM –
Please list three references: family, friend, pastor, chaplain, therapist, or probation/parole officer
Full Name_____________________________________________ Relationship_____________
Address_______________________________________________ Phone__________________
City_____________________________________________ State___________ Zip__________
Full Name_____________________________________________ Relationship_____________
Address_______________________________________________ Phone__________________
City_____________________________________________ State___________ Zip__________
Full Name_____________________________________________ Relationship_____________
Address_______________________________________________ Phone__________________
City_____________________________________________ State___________ Zip__________

Education, Employment & Income:

d H.S. Diploma GED College Military Training/ Skills_____________________
Employment Goals______________________________________________________________
Work Experience_______________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
s Employment_____________ Unemployment GAU/GAX Other______________
Total monthly Income $_________________ Monthly Payments $______________________

Legal Records:
List all arrests you have had, DUI/DWI, Misdemeanors, Felonies, Restraining Order, Arrests,
Incarcerations, & etc. (Date Arrested/Charges/Results & Date) *Attach separate sheet if necessary
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Do you have pending charges/upcoming cases? (Y/N) When_________ Reason_____________
Are you presently on probation or parole? __________ How long? _______________________
Name of Officer______________________________________ Phone____________________
Name of Attorney____________________________________ Phone_____________________
Have you ever been involved in a domestic violence situation? (Y/N)______________________
_____________________________________________________________________________
Is an order of protection against you in the State of Missouri? (Y/N)
Explain_______________________________________________________________________

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FREEDOM CITY MINISTRIES
ABBA’S HOUSE – APPLICATION FORM –
Medical History: (*Attach separate sheet if needed)
Have you ever been under a doctor's care for any reason in the last year? (Y/N) If yes, please indicate
duration____________________________________________________________________________
___________________________________________________________________________________

Do you take medication or need medical attention regularly? (Y/N) If yes, indicate medicines/dosage
and attention needs__________________________________________________________________
__________________________________________________________________________________

Do you have a disability, artificial limb, wear a brace, service dog, or have a handicap of any kind?
(Y/N) If yes, please explain_____________________________________________________________

Have you ever had high blood pressure or any kind of heart disease? (Y/N) Current treatment:
___________________________________________________________________________________

Have you ever had any sexually transmitted diseases? (Y/N) If yes, state which one(s) and when
treated_____________________________________________________________________________
Date of your last physical checkup: _____________ Doctor: __________________________________

Have you ever received treatment or counseling for emotional/psychological problems? (Y/N) If yes,
please give details____________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________

Have you ever been hospitalized or taken to the emergency room as a result of drug abuse and/or
alcoholism? (Y/N) If yes, when? ________________________Details___________________________
___________________________________________________________________________________

Have you ever been treated for any of the following? □Bipolar □PTSD □Depression
□Anger □Schizophrenia □Self-Mutilation □Suicide Attempt □Dissociative Disorder
□Borderline Personality Disorder □Other: ________________________________________
Current Counselor or Psychiatrist: Name: _____________________ Phone: _______________
City: ________________________ Organization: _____________________________________
Last psychological evaluation: Date _____________ Service Provider: ____________________
CurrentTreatment/Medications:___________________________________________________
_____________________________________________________________________________
How would you describe your current mental state? __________________________________
_____________________________________________________________________________

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FREEDOM CITY MINISTRIES
ABBA’S HOUSE – APPLICATION FORM –
Personal Habits & Addition History:
List all drugs and/or narcotics, legal or illegal, (and years used) you have abused. (Circle the most
heavily used).________________________________________________________________________
___________________________________________________________________________________

Do you use tobacco (Y/N) How long? ___________ What was the first drug you abused? ___________
Which substances have you used? Methamphetamine □Y □N Date last use: __________
Marijuana □Y □N Date last use: _______ Alcohol □Y □N Date last use: __________
Cocaine □Y □N Date last use: _______ Heroine/Opiates □Y □N Date last use: __________
Hallucinogens □Y □N Date last use: _______ Inhalants □Y □N Date last use:__________
Other Prescriptions □Y □N What kind: _____________________ Date last use: __________
Drug(s) of choice: ______________________________________________________________
Have you ever been involved with homosexuality? (Y/N) Have you ever participated in witchcraft or
occult practices? (Y/N) Please explain:____________________________________________________
___________________________________________________________________________________
Treatment History:

Out Patient In Patient Where Complete? Date Length

Current Treatment/Recovery Support:

Name: ________________________________Phone: ______________ City: ______________
Organization: __________________________________________________________________

Faith/Affiliation:
Have you ever had a conversion experience with Jesus Christ? _____(Born again, accepted Jesus, etc.)
Explain in detail:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
What church have you attended most? __________________________ How long? _________

Current Situations:
Are you in a romantic relationship of any kind, including emotional? (Y/N) If yes, please explain
_____________________________________________________________________________
_____________________________________________________________________________
s
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FREEDOM CITY MINISTRIES
ABBA’S HOUSE – APPLICATION FORM –
If you are in a romantic relationship with anyone, that means emotional or physical could be a
breach to your contract, we encourage you to put it on hold while you are at Abba’s House.
(Excluding Marriages) When you are ready to live on your own, then you will be more
prepared for a relationship. Remember, you signed a contract, and this is part of it. This
window of time is for you to get your relationship with God in order. We hope and pray that
one day you’ll find your bride a blessed gift from God.

Common Concerns in life: (Please rate 0=none, 1=mild, 2=moderate, 3=severe)

___ marriage ___ divorce ___ alcohol ___ weight control ___ work
___ family ___ sexual ___ singleness ___ depression ___ grief/loss
___ anxiety ___ past hurts ___ mood swings ___ drugs ___ children
___ intimacy ___ stress ___ self-esteem ___ anger control ___ housing
___ abuse ___ other addictions ___ other ___________________
Please state your current plan to address the above concerns: __________________________
_____________________________________________________________________________
_____________________________________________________________________________
COVENANT/RELEASE OF INFORMATION AGREEMENT
I, ______________________________, agree to abide by all policies and requests, written or verbal, of
Freedom City Ministries (Abba’s House Restoration) and its staff. I agree to random drug screens whenever
requested by staff. I hereby release all information pertaining to my residency for the express use of Abba’s
House Restoration/Freedom City Ministries, its staff, and any other affiliates, organizations, or institutions
deemed necessary by Freedom City Ministries' staff. I wish to enroll into Abba’s House’s Program, a 6 month -
1 year discipleship and accountability program. I realize that I am here voluntarily and am free to leave
whenever I choose. I acknowledge and agree that Abba’s House Restoration/Freedom City Ministries, its staff,
or members are not responsible for any accident or injury.
I certify that the answers given here are true and complete to the best of my knowledge. I understand that
false or misleading information in my application may result in my release. I authorize Abba’s House
Restoration/Freedom City Ministries’ staff to make any necessary inquires to evaluate this application.

Applicant’s Signature: ___________________________________________ Date: ____________

Send applications to: Questions:
Mail: Freedom City Ministries Contact: Joe Burkholder
h PO Box 972 Phone: (660)605-3050
g Chillicothe, MO 64601 Email: [email protected]
Email: [email protected]
*Please understand that we may not be able to respond to your application right away. Applications are on a
first-come, first-serve basis. We pray God will help you to see and surrender to your next step of obedience.
www.freedomcityministries.com

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