PLEASE READ THESE INSTRUCTIONS CAREFULLY BEFORE APPLYING

Thank you for your interest in the LifeChange Program at the Bread of Life Mission.  Please fill out the application carefully and completely. Incomplete applications will result in a delay for intake interview.

Upon completing the application in its entirety, check in at the front desk to schedule your intake interview appointment. Interviews are held on Mondays at 1 pm.  

Rules and Requirements:

  • You must be at least 18 years old to apply for the Program.  You must have valid state identification.
  • You must be prepared to enter the Program immediately upon acceptance.
  • If you require detoxification, the Program does not conduct detox nor arrange for it.  Detox must be arranged and accomplished prior to intake interview by the applicant.
  • A minimum thirty (30) day restriction period commences upon entry into the Program. 
  • Any scheduled appointments that will violate compliance with this requirement will result in non-acceptance.
  • No phone calls, outside appointments, or visitors are allowed during the restriction period.
  • If you require prescription medication, you must have enough to get you through the restriction period.
  • The Program is a 12-month residential recovery program.  No outside employment or schooling concurrent with Program will be authorized until the Transition Phase, which is the final 4 months of the Program.
  • The Program is Christian based.  Residents are expected to attend Christian church, Bible studies, and other Christian activities as part of the Program.
  • ALL pending legal issues (e.g., court dates) must be reconciled prior to the interview.
  • If you are late for the intake interview, you will not be interviewed on that day and will be removed from the list.
  • The Program requires a considerable amount of reading and writing.  If you are unable to read and comprehend adequately, you may be denied entry into the Program.  If your command of the English language is not adequate to understand course material, you will be denied acceptance.
  • Medical and psychological diagnoses may or may not be an issue for admittance.  Each is handled on an individual basis.  Some diagnoses are beyond the capabilities of the Program to accommodate.
  • All medications must be disclosed and turned into staff upon admission.
  • Any applicant taking prescription narcotics will not be accepted.
  • Applicants on the Methadone program will not be admitted.
  • All applicants must be willing to submit to a UA/breathalyzer test on the day of intake.  Positive UA/breathalyzer tests may result in delay or non-acceptance.
  • Applicants who are inebriated will not be interviewed.
  • A criminal history will not suspend you from application or acceptance to the Program.  Sex offenders are NOT eligible for our Program.
  • There must be full and honest disclosure on this application.

Name *
Name
Address
Address
If you do not have a current address leave blank
Must be 18+ to be eligible
Are you *
Are you a U.S. Armed Services Veteran? *
Highest Education Level Completed *
If you answered yes, when did you apply?
If you answered yes, when did you apply?
Emergency Contact Person *
Emergency Contact Person
Contact Address *
Contact Address
Contact Phone *
Contact Phone