Apply for Faith-Based Rehab near Tuscaloosa, Alabama

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Application for Faith-Based
Recovery at Genesis Mission

The first step is applying — and that’s often the hardest part. But it only takes about a minute, and it brings you one step closer to an entirely different life.

First name*

Last name*

Email address*

Phone number*

Street Address*

City, State & Zip*

Date of Birth*

Month

Day

Year

Gender*

Male

Female

Marital Status*

Single

Married

Divorced

Separated

MINOR CHILDREN: Do you have minor children?*

Yes

No

MINOR CHILDREN: If yes, do you have legal custody?*

Yes

No

Not Applicable

Are you prescribed any medication?*

Yes

No

MEDICATIONS: If yes, please describe:

Are you on probation or parole?*

Yes

No

PROBATION / PAROLE: If yes, where?

SEX OFFENDER: Are you now or have you ever been required to register as a sexual offender? If so, please explain.

COURT DATES: Do you have any upcoming court dates? If so when and where?

Have you ever been to a Mission Teens center? If so, when?*

What's the main issue in which you're seeking help?

Who were you referred by?

genesismbtc@gmail.com

(205) 267-0293

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Application for Faith-Based Recovery at Genesis Mission

Application for Faith-Based
Recovery at Genesis Mission