Gender
Select… Male Female
Phone number
Phone type Mobile Home Work Other
Marital status
Select… Single Married Widowed
What challenges are you currently facing? *
How long have you been struggling with these challenges? *
Select… Less than one year 1 to 2 years 3 to 5 years More than 5 years
Have you sought help for these challenges before? *
Select… Yes No
What are your hopes for our program? *
Do you currently live with someone? *
Select… Yes No
Do you have a support system? *
What is your current living situation? *
Select… Stable Homeless
Do you have any legal issues? *
Select… Yes No
Do you have any medical conditions *
Select… Yes No
Are you taking any medications *
Select… Yes No
What do you hope to gain from the Ignite Discipleship Center program? *
Are you willing to participate in Bible studies, praise and worship, church services, and other activities, including chores? *
Select… Yes No
Are you willing to live in a structured, community-based environment? *
Select… Yes No
Are you willing to commit to a one-year program? *
Select… Yes No
Submit
