Application Form

We trust God to bring to the Women’s Refuge all who will find healing and restoration through our program!

After completing this portion of the application, we will contact the applicant via phone or email to make an appointment for the interview.
After the interview, the counseling staff will make a decision whether the applicant is appropriate for our residential program at this time.

Are you human?
Leave this empty if you are a human. This is to prevent spam.

Last Name

First Name

Middle Name

Address

City

State

Zip Code

Email Address (If Available)

Phone Number

Date of Birth

Age

This Application is for our:

Personal Profile

2. What is your past & present relationship with your parents or others who reared you?

Your brothers and sisters?

Your husband or boyfriend?

Your children?

3. What was your home atmosphere like?

4. Are you prejudiced against groups, races, or nationalities?

5. Are you appreciated and liked by others? What do others appreciate about you? What makes you likeable?

6. In your opinion, what constitutes success? In other words, describe what makes a person worthwhile or successful?

7. How does your opinion of success compare to God’s evaluation of success?

8. List your three biggest fears – the things you dread most or the worst things that could ever happen to you:

9. Describe how you decide between right and wrong or the basis or method you use in deciding what to do, say, or think

10. Who is Jesus Christ and what does He mean to you and your life?

11. DENOMINATION/Church Name

FINISH THE FOLLOWING SENTENCES WITH TWO OR THREE ANSWERS EACH

1. I am

2. I like

3. I am happy

4. I am unhappy

5. God is

6. A happy home

7. I want

8. I dislike

9. I become angry

10. My greatest failures are

11. My chief sins are

12. I can

13. I can't

PERSONAL HISTORY FORM

PRESENTING PROBLEM:

What is your chief problem to be resolved?

Are you seeing or have you seen anyone for counseling previously?

Are you open to God’s solution to the problem?

RELATIONSHIPS AND PARENTS:

Are your parents married, living together now?

What kind of person was your mother?

What kind of person was your father?

How did your mother praise you – what did she say?

How did your mother criticize you – what did she say?

How did your father praise you – what did he say?

How did your father criticize you – what did he say?

If you had stepparents, how were you treated by him / her?

How were your brothers or sisters treated by your parents / stepparents?

As a child, were you closer to your Mom or Dad?

Which could you talk to about a threatening matter, if either?

Did either parent express or show love?

Was favoritism shown to other siblings by your parents?

Were either or both of your parents overprotective? Describe.

When you were punished as a child, what was mild and what was severe?

Which punishment was most common?

EDUCATION LEVEL:

EARLY LIFE:

What is the worst memory you have of your early life as a child? How old were you?

What was your best memory as a child? How old were you?

What feelings, thoughts, or attitudes were you not to reveal in your childhood?

Do you now feel that there are thoughts or attitudes or feelings that you should not talk about concerning your childhood?

Were there any significant happenings to you prior to school?

How did you relate to siblings?

What did you say and believe about life when in grade school?

Describe yourself from ages 6-12

How many close friends did you have from ages 6-12?

Were you ever sexually abused as a child?

Any significant changes in your attitudes toward yourself or others in Jr. High school?

High School:

What did you say and believe about life as a teenager?

When did you start dating? Any steadies?

What is your best memory of your high school days?

What is your worst memory of your high school days?

Were there any sexual development problems or sexual relationships during high school?

Did you complete high school?

How did you get along in high school? Many friends?

College:

Briefly describe your college years

Did you complete college?

Were you sexually active during college?

How did you get along in college? Many friends?

MARITAL STATUS AND OCCUPATION:

At what age were you married?

If married, how would you describe your sexual adjustment?

What is your occupation?

What is your spouse’s occupation?

Are there any excessive financial pressures at this time?

Do you agree on money management?

Describe your communication with your spouse

Do you have children?

If so, tell me about them and describe your communication with them

Have you ever been involved in homosexuality?

If so, date of last relationship

Have you ever been involved in the following occult activities:

Witchcraft

Satan worship

Yoga

Astrology

Ouija Boards

New Age

Fortune Telling?

Other

To what extent have you been involved in these activities?

Have you been in counseling for your participation in these activities?

With whom did you counsel? (Name and Address)

Do you believe that the above involvements are lies of Satan and none of them are related to God’s will for your life?

MENTAL AND EMOTIONAL HEALTH:

Do you ever feel depressed or anxious?

Describe the feeling you most often have when you feel upset or uncomfortable

How early in your life do you remember such feelings?

Have you experienced sexual abuse as an adult?

Do you ever have thoughts of suicide?

Have you ever used illegal drugs?

Describe the significant losses in your life, whether persons, places or things

List three character references (Not related)

Reference 1

Name

Address

Phone Number

Email Address

Reference 2

Name

Address

Phone Number

Email Address

Reference 3

Name

Address

Phone Number

Email Address

I certify the above is true and accurate to the best of my knowledge. I realize this information will be kept confidential.

Signature

Date

* Please fill out all required fields

Error: Please check the reCAPTCHA

Submit

Thank you - your form was successfully sent

772-770-4424

772-770-4424

Application Form

Personal Profile

FINISH THE FOLLOWING SENTENCES WITH TWO OR THREE ANSWERS EACH

PERSONAL HISTORY FORM

MENTAL AND EMOTIONAL HEALTH:

List three character references (Not related)

Contact Us

Our Hours

Stay In Touch