Apply — Tribe of Levi Discipleship Program

Personal Information

Basic identifying information about yourself.

First Name *

Last Name *

Middle Name

Alias / Nicknames

DOC Booking Number

Current Address

City and State of Birth

Date of Birth *

Phone Number *

Email Address

Emergency Contact

Documentation & Identification

Do you have a valid driver’s license?

Yes No

If yes, License Number and State

Do you have a state 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

Preferred Location *

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?

Describe your relationship with your family (parents, siblings, extended family)

Describe your childhood

Have you experienced any significant losses in your family, such as 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 & Triggers

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

Yes No

If yes, please explain which addictions

What triggers cause you to resort to addictive behaviors?

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 find a mentor for accountability after release?

Yes No

If no, please explain

Do you have difficulty controlling your anger?

Yes Sometimes No

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

Counseling & Mental Health

Have you had 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 & 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?

What are your specific plans for the future?

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

Acknowledgment & Signature

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.

Type your full legal name as signature *

Date *

Your information is kept confidential and never shared with law enforcement or other agencies.

Application

Personal Information

Documentation & Identification

Incarceration & Legal Information

Family Information

Addictions & Triggers

Counseling & Mental Health

Spiritual Journey & Program Commitment

Post-Release Planning

Acknowledgment & Signature

Application Received