Program Application

All prospective clients must complete the form below. It will be sent to our program team for review prior to any potential intake into our 12-month life-transformation program.

Name

First Name

Last Name

Date of Birth

YYYY

Sex

Who is completing this form?

Email Address

Phone Number

(###)

###

####

Current Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Best way to contact you

Have you ever stayed at WRM before?

How did you hear about the program?

Reason for wanting to enroll into WRM's program

Are you currently or soon to be experiencing homelessness?

Are you fleeing from someone?

What is your marital status?

Are you required to pay child support?

Are you currently receiving any form of income?

Are you currently employed?

Are you currently in school or in a training program?

Are you a veteran?

Have you been prescribed any medications for a physical and/or mental health diagnosis?

Do you have a mental health diagnosis?

Have you ever been arrested?

Have you been charged with any violent crimes?

Have you been convicted of a crime involving children or the elderly?

Are you a sex offender?

Do you have any pending charges?

How can we pray for you?

Disclaimer

Winchester Rescue Mission (WRM) is not a medical or psychiatric facility. To help us make informed decisions and ensure the best fit, we may request medical or mental health information. If later it's found that our program isn't the right match due to undisclosed medical or psychological concerns, we may recommend alternative options or collaborate with referring agencies. Please know your well-being is our top priority.

I understand and agree to the above statement

Type your name below

This will serve as your electronic signature