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Mission Statement
Vision Statement
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>
Falls
Stephenson
Pegues
Byers
Jackson
Rimmer
Ferguson
Board of Directors
>
Vallory Combs
Sheila Stephenson
Ian Spillman
Christina Periman
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Stephanie's Wish
5k Walk
>
5k Walk
Dads Goes to School Initiative
>
Fatherhood Drawing Winner
Growth & Development Conference
Celebrate Recovery Month Event
Youth Power Summer Camp 2011
Youth Power Summer Camp 2010
Open House & Ribbon Cutting Ce
Fresh Start House
Meet PCDC
Litter Pick Up Day
Superbowl Party
Renovation Pics
Kids @ Sesame Street Show
Powerhouse Praise Dancers
Youth Power in Action
In The News
Resources
Central Missouri Behavioral Health Network
Christmas Character Costume/Holiday Face Mask Contest
Incarcerated and Detained Application
*
Indicates required field
Name
*
First
Last
Doc Number
*
Complete DOC Address
*
Line 1
Line 2
City
State
Zip Code
Country
Phone Number if available
*
Social Security Number
*
Date of Birth
*
Marital Status
*
Married
Single
Divorced
Widowed
Name of spouse or ex-spouse
*
First
Last
If married tell us a little about the situation:
*
Legal Status: What county are you supposed to parole to? (What county did you get convicted in, what county is your plan supposed to be in)
*
What was the conviction for?
*
Do you have any sexually related offense(s):
*
No
Yes
Do you have any violent offense(s):
*
No
Yes
Do you have any drug related charge(s):
*
No
Yes
Name of current institution Probation/Parole Officer or Case Worker if you know who it is:
*
Phone and Extension
*
Are there any circumstances regarding your Probation/Parole?
*
What is your expected release date? How certain is that?
*
How much time have you served this incarceration?
*
How much time total have you spent incarcerated in your life?
*
Past drug or alcohol use:
*
Have you ever been in a drug or alcohol treatment program? If yes how many?
*
What type of drugs have you dealt with?
*
Are you taking prescription medication? If yes why are you prescribed medication? (Explain purpose)
*
Name the medication(s) you take:
*
When was your last doctor's appointment for your medication(s)?
*
Have you ever been admitted to a mental facility or a mental treatment program? If yes where, how long and for what?
*
Spirituality: Do you see God as a part of your life? If yes explain.
*
Past work experience? Explain.
*
Relationships: Are you in a committed "romantic" relationship? If yes, how long, do you feel its a healthy relationship and why or why not?
*
How many kids do you have?
*
Do you have a relationship with your kid(s)?
*
Emergency Contact:
*
First
Last
Emergency Contact Relationship:
*
Emergency Contact Phone Number:
*
Why do you want to live at the Fresh Start House?
*
Do you feel you have a problem with decision making, alcohol or drugs? Explain.
*
List a few short term goals for your life (the next six months):
*
Please state any other information that you thinik might be helpful so that we can serve you better:
*
Submit
Home
About Us
From the Desk of the Executive Director
Blog
Contact Us
Mission Statement
Vision Statement
PCDC Staff
>
Falls
Stephenson
Pegues
Byers
Jackson
Rimmer
Ferguson
Board of Directors
>
Vallory Combs
Sheila Stephenson
Ian Spillman
Christina Periman
Organizational Chart
Affiliates
Partners
Programs
COVID-19 FOOD PROGRAM
GED Program
Summer Food
Community Garden
Summer Camp
Recovery Support Services
Domestic Violence
Fresh Start
>
Missouri Reentry Program
Youth Power
Fatherhood
>
Fatherhood Program
Dad Goes to School Initiative
Connecting with Your Kids
Focus on Fatherhood
First Offenders Program
Donations
Media
Youth Power Summer Camp 2016
Stephanie's Wish
5k Walk
>
5k Walk
Dads Goes to School Initiative
>
Fatherhood Drawing Winner
Growth & Development Conference
Celebrate Recovery Month Event
Youth Power Summer Camp 2011
Youth Power Summer Camp 2010
Open House & Ribbon Cutting Ce
Fresh Start House
Meet PCDC
Litter Pick Up Day
Superbowl Party
Renovation Pics
Kids @ Sesame Street Show
Powerhouse Praise Dancers
Youth Power in Action
In The News
Resources
Central Missouri Behavioral Health Network
Christmas Character Costume/Holiday Face Mask Contest