Contact Us

We are a ministry in building and we can at times offer support anyone who is sincere about making their lives more meaningful and free of drug or alcohol dependencies. We do not at this time have live in facilities, but we can help you with some spiritual guidence, rehab placement or job assistance. Just fill out the contact form below and we will get back with you as soon as possible.

New Life Discipleship Questionaire
Application Date *
First Name: *
Last Name: *
Current Address:
City:
State:
Zip:
Current Phone Number: *
Cell Phone Number: *
Email: *
Do You Consume Alcohol ? *
How Much Alcohol Daily ? *
Do You Take Drugs ? *
Drugs Per Day ?
Would You Take An Drug/Alcohol Test Now ? *
Can You Pass A Test ? *
Male or Female ? *
Social Security Number ?
Have You Been Convicted of a Crime ? *
If Yes, Explain What Crimes *
Are You On Probation/Parole *
Do You Have Court Dates ? *
Do You Have Medical Problems ? *
Are You Under A Doctor's Care Now ? *
Are You A Registered Sex Offender ? *
List All Employment Skills *
Will You Enter A 1 Year Discipleship Program ? *
Will You Obey All Rules ? *
Reload image

Application Date *
First Name: *
Last Name: *
Current Address:
City:
State:
Zip:
Current Phone Number: *
Cell Phone Number: *
Email: *
Do You Consume Alcohol ? *
How Much Alcohol Daily ? *
Do You Take Drugs ? *
Drugs Per Day ?
Would You Take An Drug/Alcohol Test Now ? *
Can You Pass A Test ? *
Male or Female ? *
Social Security Number ?
Have You Been Convicted of a Crime ? *
If Yes, Explain What Crimes *
Are You On Probation/Parole *
Do You Have Court Dates ? *
Do You Have Medical Problems ? *
Are You Under A Doctor's Care Now ? *
Are You A Registered Sex Offender ? *
List All Employment Skills *
Will You Enter A 1 Year Discipleship Program ? *
Will You Obey All Rules ? *