Blank Application — Tribe of Levi

Personal Information

Full Name (First, Middle, Last):

Alias / Nicknames (if any):

DOC Booking Number:

Present Address (Street, City, State, Zip):

City and State of Birth:

Date of Birth (MM/DD/YYYY):

Phone Number:

Email Address:

Emergency Contact (Name, Phone, Relationship):

Documentation and Identification

Do you have a valid driver’s license?

Yes No

If yes, License Number and State:

Do you have a state-issued ID, birth certificate, and Social Security card?

Yes No

If no, which documents are missing?

Are you a veteran?

Yes No

If yes, type of discharge from service:

Incarceration and Legal Information

Current or Most Recent Facility Name & Unit:

Facility Address:

Incarceration Start Date:

Expected Release Date:

Will you be on probation or parole upon release?

Yes No

If yes, how long will you be on parole?

Do you have to register (e.g., sex offender registry)?

Yes No

KDOC Number:

Name of Probation/Parole Officer:

Officer Direct Phone Number:

How often do you report?

In-person Email Phone

Do you owe court fines?

Yes No

Amount owed:

Due Date:

Have you ever been charged or convicted of a sex crime?

Yes No

If yes, please explain:

Have you ever been convicted of domestic violence?

Yes No

If yes, please explain:

Do you currently have a restraining order against you?

Yes No

If yes, who filed it and your relationship to them / when does it expire?

Have you ever been, or are you now, affiliated with any gangs?

Yes No

If yes, which gang, age when affiliated, and how long?

Do you have any unresolved conflicts with people outside of prison?

Yes No

If yes, please explain:

Total cumulative time served in prison:

Number of times incarcerated:

List all crimes for which you have been indicted and/or convicted (and time served for each):

Did you receive any DRs (Disciplinary Reports) while in prison?

Yes No

If yes, please list them:

Have you used drugs while being incarcerated?

Yes No

Family Information

Do you have children?

Yes No

If yes, list their names and ages:

Where do your children currently live?

Describe your relationship with your children:

How will you respond if the ministry restricts you from a potentially harmful relationship with a family member or friend?

Please describe your relationship with your family (parents, siblings, extended family):

Describe your childhood:

Have you experienced any significant losses in your family (suicide, murder, or other traumatic events)?

Yes No

If yes, please explain:

Are you married or do you have a significant other?

Yes No

If yes, their name:

Addictions and Triggers

Have you ever struggled with addictions besides drugs/alcohol (sexual, smoking, pornography, gambling, cutting, co-dependency)?

Yes No

If yes, please explain:

What triggers cause you to resort to addictive behaviors? (e.g., stress, loneliness, financial struggles, relationships)

List all programs you have completed to address your addictions:

Are you willing to participate in the program to address your addictive behaviors?

Yes No

Are you willing to agree to find a mentor for accountability after release?

Yes No

If no, please explain:

Do you have difficulty controlling your anger?

Yes No Sometimes

If yes or sometimes, how do you typically handle anger?

Counseling and Mental Health History

Have you had any professional counseling in the past?

Yes No

If yes, type of counseling and duration:

Have you ever been in juvenile detention?

Yes No

If yes, at what age?

Spiritual Journey and Program Commitment

Have you accepted Jesus Christ as your Lord and Savior?

Yes No

What role does your faith in Jesus Christ play in your recovery and healing journey?

What does being a disciple of Christ mean to you? How do you want to live out that role?

How will you respond when the ministry enforces a rule that you do not understand or agree with?

Post-Release Planning

What concerns do you have about being released?

What difficulties do you believe you will face once released? (e.g., finding work, rebuilding relationships, staying sober)

What are your specific plans for the future? (e.g., job, housing, faith journey)

How do you feel this program can help you achieve those plans?

I acknowledge that all the information I have provided is true and complete to the best of my knowledge. I understand that The Tribe of Levi Ministries is a faith-based discipleship program with rules and expectations centered around Christian principles, and I am willing to commit to this lifestyle for the duration of my stay.

Signature (full legal name):

Date:

Submitting your application: Email the completed form to info@tribeofleviks.org, or call (316) 882–1676 to arrange hand-delivery. You can also apply online at tribeofleviks.org/residential-inquiry/apply/.

The Tribe of Levi Ministries — Wichita, KS

Application for Discipleship Program