Application

Application Online:

The cost of the program is $125 per week.  If necessary we will assist you in getting food stamps, etc.
No personal money is allowed for the first three months.

Admission to the program is based on your willingness to make a 100% commitment of your life to the Lordship of Jesus Christ. Without that total commitment, there can be no lasting or genuine change in your life, and it provides the foundation for all training and instruction received in this program. Applications will be carefully screened to determine eligibility. The interviews will then be arranged by appointment and held at the facility in Darien Center, NY.

Name *

First

Last

Date *

mm/dd/yyyy

Phone Number *

555-555-5555

Current Address: *

Address | City | State | Zip

Birthday *

mm/dd/yyyy

Sex *

• Male
• Female

Height *

Weight *

Race

Marital Status *

• Married
• Single
• Girlfriend/Boyfriend
• Divorced
• Separated
• Widowed

Please provide accurate legal status of marriage

US Citizen *

• Yes
• No

Referred By:

SSN

Type of Photo ID

Photo ID Number

Why do you want to enter the program? *

Emergency Contact *

First

Last

Emergency Contact Info

Relationship and Phone Number

Spouse

First

Last

Only if legally married

Spouse Phone Number and Address

Do you have any children? *

• Yes
• No

How Many Children? | What is their Living Status? | Who will take care of them for duration of program?

Have you ever been to a drug/alcohol rehabilitation facility? *

• Yes
• No

If Yes, Please Explain:

Drug(s) of choice: *

Are you using now? *

• Yes
• No

Date of last use: *

Longest period of abstinence: *

Age began using:

Do you smoke or use tobacco products?

• Yes
• No

Have you ever tested positive for: *

• HIV/AIDS
• Hepatitus
• TB
• Diabetes
• Other
• None of the above

If other, please describe:

Current Medications:

Allergies:

History of psychiatric medication:

Do you have any disabilities or physical problems?

Please explain to the best of your ability

Do you have any current physical problems that hinder you from working? *

• Yes
• No

Highest Grade Level Completed: *

Year *

Vocational/Job Training/College:

Type of trade experience:

Reading/Writing Fluency *ExcellentGoodFairPoor

Application will not be refused based upon this answer.

Are you currently on: *

• Probation
• Parole
• Warrant for Arrest
• No Legal Matters

If other than "No Legal Matters", please explain:

Please provide probation/parole information including Contact information and your responsibilities.

Criminal History

Please be as thorough as possible. Cases and charges not listed can be considered an immediate refusal for admittance.

Cases Pending: *

#

Please explain your financial circumstances: *

Do you currently receive: *

• SSI
• SSD
• Medicaid
• Food Stamps
• Unemployment
• Other
• None of the above

Church Affiliation:

Is Jesus your Lord and Savior *

• Yes
• No
• I don’t know

Are you willing to do whatever it takes to get set free, and stay set free, from drugs, alcohol, and destructive lifestyles? *

• Yes
• No
• I don’t know

Electronic Signature *

First

Last

By typing your name, you are verifying that the above information is complete to the best of your ability. You also verify that the application is being submitted by the person whose name is on this application. From this signature you are agreeing to follow our policies and procedures for the duration of the program. May the Lord bless you and keep you!

Submit

Program Rules Agreement

The following are some of the basic rules of Freedom Fellowship’s Total Freedom Program.  You will be provided with a complete list of rules upon admittance.

Christian Growth Center:

1. I understand that Total Freedom Program is a Christian Growth Program and I agree to be subject to Biblical teaching and Christian forms of behavior.

2. I agree to assume personal responsibility for my own attitude and behavior at all times. I understand that what program authority calls incorrect behavior and a bad attitude will be confronted and may be disciplined if necessary. I will agree to do the disciplinary action or project with an improved attitude.

3. I understand that my main purpose for being in the program is to learn how to live a new way of life.

Personal:

1.  I will do whatever it takes to get set free and stay set free.

2.  I will not possess or use drugs, alcohol, or tobacco products at any time while in the program.

3.  I will not curse or use off-color expressions or bodily gestures.

4.  I will not talk about street life or reminisce about past wrong doings.

5.  I will not horseplay or engage in any other inappropriate body contact.

6.  I will not become part of a clique.

7.  I will not call other people names.

8.  I will not go off campus without staff permission.

9.  I will not bring any electronic devices, secular books/magazines, knives, lighters, etc.

10.  I will not sing, whistle, or hum secular songs while in the Program.

11.  I will follow all guidelines posted in the house and given by staff.

12.  I will not borrow from others without permission from office.

13.  I will not read or look at sexual material or pornography or participate in sexual activities while in the program.

14.  I will give my all completely and with 100% honesty.

Family:

1.  I will agree to the staff screening and perhaps reading my mail.

2.  I agree to write only members of my immediate family – no letter writing to girl/boyfriends.

3.  I agree to make (or receive) only two phone calls per week, after a 14-day waiting period.

4.  I agree not to have any visits from my immediate family until after 14 days.

5.  I agree not to pursue relationships with the opposite sex while in the Program and that same sex relationships are not allowed.

Group:

1.  I agree to participate in all scheduled activities including class, chapel, church, work, and recreation. I will do what I’m required to do in each of these activities on time.

2.  I agree to conduct myself in a Christ-like manner and will not do anything in public that will call attention to myself or reflect badly upon the whole group.

3.  I agree to submit to all authority and respect one another in all things.

4.  I understand the length of the program is 9 months. I agree to commit to complete the entire program.

Discipline:

1.  I understand that I’m expected to be prepared, in place, and on time for all my scheduled activities 24 hours a day. I also understand that any tardiness, unpreparedness, and other forms of carelessness will result in disciplinary action.

2.  I understand that the house and my room must be kept in a neat and orderly manner at all times. I agree to work together with my housemates to keep it clean and in shape for inspection.

3.  I understand there will be a dress code: no logos with alcohol, drugs, or demonic pictures, lettering or slogans.

4.  I understand there will be a grooming code: neat and clean appearance at all times, i.e. hair combed throughout the day, and shower once a day, etc.

5.  I understand that disciplinary action may include: extra duty, loss of privileges, suspension, or dismissal.

6.  I waive all rights to pursue any legal action against Freedom Fellowship or Total Freedom Program or any personnel or volunteer.  We are not responsible for any accident or injury you may sustain while enrolled in the program.  Failure to comply with this contract may result in disciplinary action as stated above.

I have read these rules and my signature indicates that I have a good understanding of them and that I’m willing to commit myself to these agreements for the duration of the program.

Who we are:

Total Freedom New York is a residential, faith-based alternative to addiction
treatment. It was established in 2012 under the ministerial umbrella of Freedom
Fellowship; with the intention of helping men and woman heal and reclaim their
lives from destructive lifestyles. Our focus is on promoting balance of spirit, mind,
and body through a lifestyle transformation. Working through each of the various
phases people will transition into a more stable and productive life.

Total Freedom is a nine-month residential commitment followed by 12-months of
proven accountability off campus. The first four to six months is spent in classroom
and in volunteer work. For the remaining months you will enter back into the work force.
Upon completion of nine months you can choose to remain on campus and stay
accountable to this ministry or you can move on and remain accountable to another
ministry.

For the first few months you will go through a ministry school of the Spirit with daily
quizzes and a final exam. You will also go through a healing process which deals with
issues from your past, and a deliverance session. We gather together every night for
groups, bible study or worship; you are expected to be there. You must be able to read
and write English well and be willing to teach what you learn. You will also be expected
to be productive in the program in one or more of the following areas: housekeeping,
farm & garden, yard, building & repair, kitchen and various projects designed to earn
income to support the ministry.

We are a Spirit-filled ministry. We believe in the baptism of the Spirit, laying hands on
people while praying, praying in tongues, casting out demons, teaching the truths in the
Word of God, and actively praising and worshipping the Lord and you will be trained to
do the same.

The cost of the program is $125 per week. We appreciate financial assistance from family
and loved ones; however, we don’t allow lack of funds to determine eligibility. If
necessary, we will assist you in getting food stamps, etc. No personal money is allowed
while in the first phase of the program.

Admission to the program is based on your willingness to make a 100% commitment of
your life to the Lordship of Jesus Christ. Without that total commitment, there can be no
lasting or genuine change in your life, and it provides the foundation for all training and
instruction received in this program. Applications will be carefully screened to determine
eligibility. The interviews will then be arranged by appointment and held at the facility in
Darien Center, NY.