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If you are looking for a Christian-based rehab program in Poplar Bluff, Missouri, Crossroads can help. Download, print, and mail the
Crossroads Application
or fax to 573-778-0699.
Download Crossroads Paper Application
Or complete and submit the application below, and it will be sent to the director.
Crossroads Ministry Application
Crossroads Ministry Application
Crossroads Ministry is Poplar Bluff's rehab program with a Christian focus. When you apply, please answer all questions as specifically as possible. BE HONEST!
Name
Age
Today's Date
Address
Address
Street Address
Street Address
Street Address
Street Address
City
City
State/Province
Alabama
Alaska
Arkansas
Arizona
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State/Province
Zip/Postal
Zip/Postal
Please check the appropriate box that describes the above address
Permanent Address
Temporary Address
Treatment Facility
Jail/Prison
Other
Other
If other, please explain.
If jail or prison, release date:
IPO Name:
DOC #:
Date of birth:
Are you currently on probation or parole?
Yes
No
Name of probation or parole officer:
Probation or Parole Officer's Phone
Probation or Parole Officer's Fax
Are you
Married
Divorced
Widowed
Single
Do you receive any of the following services?
SS Disability
SS Disability
SSI
SSI
Food Stamps
Food Stamps
Provide monthly amount in the box.
What is your primary drug of choice?
Secondary drug of choice?
Have you been diagnosed with any psychiatric or mental disorders?
Yes
No
If so, what was the diagnosis and when?
Are you taking prescription medication for anxiety, depression or pain?
Yes
No
Do you have any physical disabilities that would prevent you from physical work?
Yes
No
Have you been convicted of any violent crimes?
Yes
No
If so, describe:
Are you a registered sex offender?
Yes
No
Do you have any pending legal cases?
Yes
No
If yes, check appropriate one(s):
Traffic Violations
Civil Involvements
Criminal Involvements
How do you believe The Crossroads Ministry can help you and what are YOU willing to do?
Signature
Clear
By signing, I verify that the above information is true and accurate.
Date
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