Full Name
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First Name
Last Name
Date Application Filed
MM
DD
YYYY
Date of Birth
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MM
DD
YYYY
Best Contact Phone Number
*
(###)
###
####
Email Address
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Address before incarceration
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Last four of your S.S.#
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TDCJ #/ CID #
*
License #
*
State
*
Height
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Weight
*
Pant Size
*
Shirt Size
*
Shoe Size
*
Drivers License Status
*
Place of Birth
*
Do you have a Social Security Card/if so who has it?
*
Do you have a Birth Certificate/if so who has it?
*
Do you have a valid State ID or Driver License Card/if so who has it?
*
How was your family life growing up?
Check all that apply
Who raised you?
Please tell us about your mother.
Please tell us about your father.
Has anyone ever physically, mentally, or sexually abused you? If yes, please explain.
How old were you when you began living on your own?
Have you ever used drugs or alcohol with a family member?
If yes, please explain.
Marital Status:
Please check one
Do you have any children?
If yes, their ages?
If yes, do you have contact with them?
If yes, do you owe child support?
If yes, will you be allowed to visit your children?
If yes, where do your children live?
If yes, Do your children have the same mother/father?
If different mothers/fathers, how many?
Why would you like to become a resident at Chains of Grace Ministries?
How long do you plan on being in the program? There is no time limit on how long you can stay.
What goals have you set for yourself?
Have you applied to CoG before, if yes when?
If you have been a CoG resident, when?
What personal changes have you made since your incarceration?
What changes would you like to make in your life?
Are you a Christian?
If yes, why do you say you are a Christian?
Do you attend church?
What religion do you currently identify with?
What religions have you identified with in the past?
Have you given your life to The Lord Jesus Christ?
If no, explain why?
What religious activities/programs have you participated in while incarcerated?
What programs have you completed while incarcerated?
What is your current Chaplain’s name and phone number?
Why should we accept you into the CoG program?
Have you ever used illegal drugs?
If yes, please answer the following set of questions for as many as used.
Drug used, length of use, age first used, and the method of use for each drug?
Last drug/drugs used?
Last time used/date?
MM
DD
YYYY
Method of last use?
Have you ever been placed in a drug rehab/if yes, when?
Did you complete program?
List the first drug ever used.
Who introduced you to illegal drugs?
List problems created from your use of illegal drugs.
List all arrests involving illegal drugs.
Do you have a history of abusing alcohol?
How long did you abuse alcohol?
What type of alcohol did you consume?
How much did you drink daily?
Age first time you consumed alcohol.
Who have you abused alcohol with?
Have you ever been in an alcohol treatment program/if yes, when?
Did you complete?
Would you consider yourself an alcoholic?
If yes, why?
List problems created from your use of alcohol.
List all arrests involving alcohol
Have you ever participated in N/A, A/A, or other substance abuse programs/if yes when?
If yes to the above question, please list programs participated/completed.
If you haven’t participated in any drug or alcohol program please explain why?
What is your plan for staying clean and sober once you are released?
Highest grade completed?
High School attended?
Check all that you achieved:
Date of GED/High School Diploma Completetion:
MM
DD
YYYY
Any special courses you have taken/completed?
What college degree did you receive, what year you received it/them, and what was your major?
What educational courses have you participated in or completed while incarcerated?
Would you like to pursue your education/college in the future?
If yes, what field of study would you like to pursue?
What job assignments have you had while incarcerated/please list how long you had them for also.
Please number them and list.
Please list your former employers in the following order-most recent to the oldest:
Please number them and answer in the following manner: Employer Name, Position, Dates worked for, and Duties Performed
List any skills/certifications that you have that would assist you in obtaining employment:
Are you a veteran?
If yes, what benefits do you receive?
If yes, what branch of service did you serve in and for how many years?
What type of discharge did you receive?
In what capacity did you serve?
If you were NOT honorably discharged, please explain.
Did you participate in any programs for veterans while incarcerated/if so which programs?
Have you ever been hospitalized for a psychiatric condition or illness?
If yes, how many times and why?
List medications you currently take for any psychiatric condition that you have been diagnosed with:
Please number, name, list the reason for prescription, and date began taking:
List any medication you are not presently taking that you will need once released:
Please number, name, list the reason for prescription, and date last used:
List medications you have taken in the past for any psychiatric condition, if not listed above:
Please number, name, list the reason for prescription, and date last used:
List all other medications you currently take, the reason, and the date you started taking them:
Please number, name, list the reason for prescription, and date began taking:
List any medications that you aren’t currently taken that you will need once released:
Please number, name, list the reason for prescription, and date last used:
List any medical issues that will need to be addressed once you are released:
List any and all work restrictions/medical limitations that you are aware of:
List any major surgeries you have had in the past:
Please number, list surgery performed, and date (estimate) performed:
Have you ever attempted suicide? If yes, when? If yes, explain why if possible?
Have you ever tested positive for HIV? If yes, when? and if known, what was the cause?
Do you have Hepatitis, if so what type, and the date diagnosed?
Have you ever received Social Security Disability?
If yes, the reason, and date received?
Will you be filing for disability once released, and if yes, the reason?
Have you been arrested or convicted of a violent crime?
Have you ever been arrested or convicted for a sexually related offense?
If you answered yes to any of the above questions please explain the circumstances.
Age the first time you were arrested?
Reason you were arrested?
If you were a minor please list what you were arrested for?
List any and all misdemeanors or felonies that you were arrested for/and or convicted of.
Have you received any cases since your incarceration? If yes how many?
Check which ones apply:
If you received any major cases please list them.
How many times have you been to prison?
Number of times probation or parole has been revoked?
How many times have you been to ISF/for violation while on parole?
Were you under the influence of drugs or alcohol when you committed any offense?
Explain why you are currently in prison or jail? Explain your charges in your own words?
What are your plans for staying out of prison?
Please provide any additional information you feel we should know about your background.
Do you have contact with any of your family and if so which family members?
Please list the personal reference name, your relationship to them, how long you have known them, their phone #, and address:
