Name: Date · Lexington Rescue Missions’ Breaking Chains Application into the Reentry Program Page 1 of 9 ORGANIZATIONAL STRUCTURE The Breaking Chains program is a component of

Lexington Rescue Missions’ Breaking Chains Application into the Reentry Program

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ORGANIZATIONAL STRUCTURE The Breaking Chains program is a component of the Lexington Rescue Mission. Breaking Chains is a Christ centered ministry, designed to aid in the transition of men and women who are reentering society from incarceration. Breaking Chains will help bridge that transition by offering employment opportunities through Jobs For Life, and Advance Lexington. Breaking Chains aims to provide strategic life skills training, structured around biblical principles. Breaking Chains adheres to the Mission Statement of the Lexington Rescue Mission. That is, “Lexington Rescue Mission exists to serve and glorify God through Christ-centered ministry that meets the physical, emotional, and spiritual needs of hurting people in the greater Lexington area.”

VISION STATEMENT Breaking Chains’ vision is to spread Christ’s vision of helping individuals that have been impacted by incarceration. “I needed clothes and you clothed me, I was sick and you looked after me, I was in prison and you came to visit me” (Matthew 25:36).

MISSION STATEMENT

Breaking Chains honors God by offering those who are reentering society, aid towards establishing a life of independence in adherence to biblical principles, so that they will be equipped to face any obstacle that will come their way.

VALUES

The code of Breaking Chains, is designed to preserve the dignity, quality, and commitments of our individuals and community together. If we deal with the root, we can then effect the fruit. “But the fruit of the Spirit is love, joy, peace, patience, kindness, goodness, faithfulness, gentleness, self-control; against such things there is no law.” (Galatians 5:22-23)

Love: Our lives are marked by servanthood and sacrifice. Peace: We surrender to teachable moments. Patience: We develop wisdom and respect through long-suffering. Kindness: we take a listening posture and foster mutual respect. Goodness: We dedicate ourselves to holiness and hospitality.

Name: Date:

Place of Birth: Date of Birth: Social Security #: *This information is needed for background inquiries only

Phone: E-mail:

The Breaking Chains program, 444 N. Glen Arvin Ave., Lexington, KY 40588, Phone: 859.381.9600 X233


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Faithfulness: We rise to the challenge of authenticity, transparency and integrity. Gentleness: We nurture communication and connection. Self-control: We practice sobriety with purpose and passion.

INDIVIDUAL SUCCESS

Success will not be measured by materialistic accumulation of possessions. Rather, the success of each individual will be apparent by the contribution to and involvement in what has ultimate and eternal significance for oneself as well as for those people within one’s life. Success will also be measured by a healthy view of individual progress in life indicated by transformations that reflect personal spiritual development and growth. The success of an individual will be demonstrated by his participation in making a positive difference in the lives of family, friends, community, work, church, and culture. In addition, success will be measured by progress notes reflecting positive outcomes relating to achievements of individual short and long term goals formulated by the guest and in cooperation with the Case Manager. The indication of a transformed life will also be a measure of the individual’s progress.

PROGRAM ELIGIBILITY FOR ADMISSION INTO Breaking Chains 1. An applicant must be willing to be a part of a community of Christian believers and

follow staff counsel that is based on the principles of the Bible. 2. An applicant who is a believer must have a willingness to follow Jesus as His disciple

and progress in the Christian life. 3. The applicant must be committed to the program as described in this application. 4. The applicant must have or be willing to have a competent mentor. The mentor must be

a believer and an active participant of a local church. 5. The applicant must also have a competent accountability partner/sponsor who has the

freedom and courage to ask the “hard” questions. 6. Applicants must submit a completed signed application.

Breaking Chains GUIDELINES AND EXPECTATIONs

Family & Other Support Systems

Emergency Contact (mandatory): ____________________________________________ (If possible please list next of kin)

Relationship: Phone 1:

Address: Phone 2:

Email:

Who are the most important /significant people in your life right now? ______________ ________________________________________________________________________


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Marital Status: ☐ Married ☐ Divorced ☐ Separated ☐ Single ☐ Widow

☐ In a Relationship ☐ Unknown

Do you have any children? ☐ Yes ☐ No If yes, please fill out the chart below:

Child’s Name Age

Social Group Commitments

● I will commit to attending at least one (1) group meeting each week related

to my Recovery Plan, (i.e. Alcoholics Anonymous, Celebrate Recovery, Group

Therapy, Parenting Classes, Employment classes, etc.). Additional meetings

may be required depending Case Management and length of sobriety time.

● I will commit to meet regularly with a sponsor or mentor concerning my

recovery.

Current Housing Situation

Current Living Situation and location:

Do you want to leave your current living situation?

How did you hear about the Lexington Rescue Mission and the reentry program? _______________________________________________________________________

List any social service agencies, courts, or organizations are you currently working with:

Agency Contact Person Phone Number


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Are you a part of a local church? ☐ Yes ☐ No

If so, which one? _____________________________________________________________

Do you have any other support systems? ☐ Yes ☐ No

If so, who is a part of your support system?

Education

What is your highest level of education? __________________________________________

Do you have a desire to increase your education or skillset? __________________________

Employment & Finances

Do you need assistance with employment? ☐ Yes ☐ No

If yes, please fill in the information below: Employer:

What type of employment are you seeking?

☐ Full-time ☐ Part-time

☐ Permanent ☐ Temporary ☐ Day Labor What other jobs have you had? What would your dream job be? ___________________

________________________________________________________________________

What are your specific employment goals? ____________________________________

________________________________________________________________________

What are your previous work experiences?

Are you currently receiving any government benefits? ☐ Yes ☐ No

☐ Food Stamps ☐ Unemployment ☐ SSI ☐ SSDI ☐ Veterans Assistance

☐ other income sources:

Physical & Mental Health

Do you currently have a physician? ☐ Yes ☐ No Physician’s Name: Phone:

Do you currently have health insurance? ☐ Yes ☐ No

Do you have any special health or accommodation needs? ☐ Yes ☐ No


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1. If yes, please explain:

Please list any allergies you may have:

Have you been diagnosed with any physical health conditions? ☐ Yes ☐ No If yes, please list them below:

Do you have any mental health diagnosis? ☐ Yes ☐ No If yes, please list them below:

Current Medications Reason for Medications

1.

2.

3.

4. Would you be able to pass a drug test while taking these medications?

☐ Yes ☐ No ☐ Not sure

Criminal History

Have you ever been convicted of a crime? ☐ Yes ☐ No

If so please explain:

Have you ever served time in jail/prison? ☐ Yes ☐ No

If yes, please fill out the information below to the best of your abilities:

Incident Date Location (City/State)

Charge & Release Date Time of sentence


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Do you have any charges pending? ☐ Yes ☐ No

If yes, please describe your legal situation:

Check the following that you currently have:

☐ Probation Officer Name: Phone:

☐ Parole Officer Name: Phone:

Drug and Alcohol History

Has alcohol ever been an issue in your life? ☐ Yes ☐ No

Has drugs ever been an issue in your life? ☐ Yes ☐ No

If “yes” for drugs: Please list the drugs you have used:

What is your sobriety/clean date?

Have you ever attended a recovery program? ☐ Yes ☐ No

If so, how many programs have you attended? ____________

Name of Longest Program: City/State:

How long was the program?

Did you complete the program? ☐ Yes ☐ No

If yes, when did you complete the program?

If no, how long did you attend:

Fill out all the following that apply: Sponsor’s Name: Phone:

Mentor’s Name: Phone:


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Counselor’s Name: Phone:

List below the recovery support groups you currently attend.

What steps do you feel you need to take in order to maintain your recovery?

Situational Questions 1. What do you think are the root causes of why you are in need of Breaking Chains reentry

Program?

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

2. What are the most important goals you want to achieve through the Breaking Chains

reentry program for…

a. Yourself _________________________________________________________________

b. Your family ______________________________________________________________

c. Your work situation _______________________________________________________

3. How will you achieve those goals?

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________


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4. Are you willing to have a change of direction in order to improve your life? Yes No if so,

what will you do? ___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

5. What will you do when the triggers to relapse cross with the right opportunity or occasion to

relapse? What is your plan?

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

6. What part does your relationship to God and faith play in your recovery plan?

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

7. Are you currently attending a local Church on a regular basis? Yes No If so, what is the name and location of the Church? ___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

8. Do you need help with any of the following:

a. Addictive Disorders (drugs, alcohol, gambling, other)

b. Substance Abuse Treatment or counseling

c. Clothing, household goods or work equipment

d. Education or Job Training

e. Financial Matters/Budgeting

f. Food or Nutritional Needs

g. Physical Health Care

h. Managing Anger

i. Child Care Assistance

j. Transportation Assistance

k. Vocational Rehab

l. Domestic Violence

m. Legal Assistance

n. Housing Placement or Assistance

o. Obtaining driver’s license, birth certificate or ID card

p. Financial assistance with rent, utilities or car repair

q. Help with paternity establishment


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r. Help with establishing a child support order

s. Help with modifying a child support order

t. Help with child support arrearages

u. Help with establishing or modifying visitation order

v. Help with establishing or modifying custody order

w. Help in dealing with child abuse or neglect

x. Help with establishing a parenting plan

y. Help getting to visit kids

z. Medication

I have read and agree to follow LRM’s reentry program as described in this application. By signing this application it does not mean I will necessarily be accepted into the Lexington Rescue Mission’s “Breaking Chains” program. Signature of Applicant: ___________________________________________

Romans 12:2

And be not conformed to this world: but be ye transformed by the renewing of your

mind, That you may prove what is that good, and acceptable, and perfect, will of God.

Correspondence: You may mail, fax or bring the application to: Lexington Rescue Mission P.O. 1050 444 Glen Arvin Ave. Lexington, KY 40508 Phone: 859.381.9600 Fax: 859.381.9603 www.lexingtonrescue.org

http://www.lexingtonrescue.org/

Documents

Name: Date · Lexington Rescue Missions’ Breaking Chains Application into the Reentry Program Page 1 of 9 ORGANIZATIONAL STRUCTURE The Breaking Chains program is a component of