Program Application

Program Application Form

We’re so glad you’re here.
Take the first step toward your next chapter.

This application is the first step in your journey with the Starfish Program. There is no cost to participate, just a commitment to your growth, healing, and your future.

First Name

Last Name

Address

Are you planning to move? If yes, when/where?

Best phone number to reach you

Your Birthday

Number of children and ages

Do your children live with you? If so, which ones?

Are there other adults in your houshold?

Monthly Income & Source of Income

If you are currently employed please list place of employment

Check here if you have an open OFP for you or against you

If yes, please describe:

What legal issues do you need to take care of? (example, get license back, pay court fees, child custody etc.)

What are your short term goals?

Describe the things you would most like to change in your life and/or the way you feel about yourself?

Are you ready and willing to be held accountable and to move forward in your life?

Are you willing to commit to the 18 month program, and do the homework and the work necessary to change your life?

Share anything else you would like known

Your Signature

Select a date

Thanks for submitting! We will be in contact with you shortly.