Online Assessment

Latriste Graham 612-225-8830

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“If you choose to do things your way, this is not the place for you. You do it our way and you will be successful”
 
Please Read: This program is designed for serious applicants, ONLY! To enter this program you must follow all the rules/compliance to be successful or you will be terminated. You  must have some form of identification (i.d./birth certificate/social security card)
 
 We will assist you in obtaining these if needed.
 
Rules: Please initial after each line, to show you understand:
 
- NO DRUGS/ALCOHOL or drug paraphernalia of any kind will be allowed in this program if so you will be terminated.  ________
 
- Upon arrival, you will be transported to recieve a Rule 25*    _________
 
*Rule 25 is a 1-hour assessment of your drug, mental, psychological history. (you will be treated for any of these issues).
 
- Then, you will be transported to receive housing or a shelter voucher.   ________
 
* You will be sheltered based on their individual needs and program compliance. Sheltered persons must be compliant to, hours and rules hours are to be determined by their program facilities. You must follow all rules  (or you will not be in compliance with the program and there will be nowhere for you to go).   ________
 
- You must attend12 step meetings/spirituality function, daily. (church, hall, etc.),
A weekly Schedule will be provided  _______
 
 
 Questionnaire  

* Required fields
Name *
E-mail Address *
Area code/phone #:
What is your choice of drugs *
If other, please list
Unnamed
Age of first used
Date last used
How long have you been in the streets
Do you have a pimp?
? Do you have a family support system?
If yes, who
? Do you have any warrants/pending court dates/ If yes, what for *
Are you in a relationship?
Do you have children?
Children? If yes, status
Are you desperate and why?
? Why do you want to attend this program?
Mental & Behavioral Health (Check all that apply)
? Tell me three things you want to accomplish in this program?
Are you currently on probation or parole
If yes, What is your PO Name
Probation officer’s phone
Do you have any outstanding warrants?
If yes, for what offense
Are you pregnant?
If so, how many months?
What is your due date?
Emergency Contact1:
Name:
Area code/ phone #
Address:
Relationship:
Emergency Contact 2:
Name:
Area code/ phone#
Address
Relationship


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Once in Treatment Facility 
 
-You must continue to follow the rules of “Coming out of Bondage” and the treatment rules.   _________
 
* You will remain in the treatment program for an individual term based your needs. (**You will be detoxed and evaluated while in treatment center).   __________
 
- Upon completion of your treatment, you will be transported to another facility for 90 days, where treatment, classes, and activities will be reinforced. (*** You must follow the rules of “Coming out of Bondage” and the rules of the facility or you will be terminated. ________
 
You must complete all programs.   __________

By following all the rules/compliances, hard work, and determination, you will sure to be successful, after the end of this program. Good luck with your success and please be aware that, “we are here for you when you need us”.

Please Note: This information’ use is solely for the use of the coming out of bondage use and is open to law enforcement only upon a direct contact /conflict.

It will not be shared with any agency otherwise. 

Thank You,

Latriste Graham Owner/CEO

Coming out of Bondage”