RPM TRANSITIONAL HOUSING ENTRANCE APPLICATION
**The RPM Program is a Christ centered program addressing hurts, habits and hang-ups from
a Biblical standpoint. Applicants must be willing to work the program from a spiritual
standpoint and abide by the program guidelines.**
Incarcerated and Detained Application
Please fill out this form completely. If you need additional space please use the back of this form. All of your answers and
information will be kept confidential. Which home are you interested in: (circle one)
Sedalia – Jefferson City
Our program is restricted by the communities surrounding the homes and our written program manual and we are not
allowed to take violent or sex offenders.
1.Name: ________________________________________Age:_____________
2. Date of Birth: ___________ - ____________ - _____________
3. Social Security #: _______ - ____ - _______ DOC#:____________________
a. DOC Address: _________________________________________________________________________
4. Marital Status: Married, Single, Divorced, Widowed. (Circle one).
a. Name of spouse or ex-spouse _________________________b. If married tell us a little about the situation:
_______________________________________________________________________________________
5. Legal Status: What county are you supposed to parole to: (What county did you get convicted in, what county is
your home plan supposed to be in):
_________________________________________________________________________________________________
6. Do you have a sexually related offense(s): YES - NO
a. Do you have a violent offense(s): YES - NO
b. Name of current institution Probation/Parole Officer/Case worker if you know who it is:
_________________________________________________________________________________________________
c. Are their any special circumstances regarding your Probation/Parole? __________________________________
Have you seen the parole board? __________What is your expected release date:_____________________ how certain is
that ______________________How much time have you served this incarceration_______________________________
7. Past drug or alcohol use:
a. Have you ever been in a drug or alcohol treatment program? _________b. If yes how many ______________________
8. Are you taking prescription medication______ why are you prescribed medication? (Explain purpose)
What is the name(s) of the medication you take____________________________________________________________
a. When was your last Doctors visit for this medication? _________________________
9. Have you ever been admitted to a mental facility or a mental treatment program? Yes or No? ___________________
If yes - where and how long and for what? _______________________________________________________________
10. Spirituality: Do you see God as a part of your life? If yes please explain
__________________________________________________________________________________________________
__________________________________________________________________________________________________
11. Groups and Programs:
a. Do you attend church services, bible studies, AA/NA or any other program while incarcerated:
explain____________________________________________________________________________________________
12. Past work experience:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
13. Relationships:
Are you in a committed “romantic” relationship? _____________ (If Yes)
How Long? ____________ Do you feel it’s a healthy relationship? ______________ Why? _______________________
__________________________________________________________________________________________________
Do you have kids?__________ How many? __________ Do you have a relationship with your kids?________________
14. Emergency contacts:
a. Name: ______________________________Relationship: ________________ Phone #:(____) ________ - ________
15. Why do you want to live at the RPM ?
16. List some short-term goals for your life (the next six months).
17. Any other information that you think might be helpful so that we can serve you better:
You can have this form sent to us in one of the following ways: Mail: RPM, 1575 Fairway Drive, Sedalia,
MO 65301 Fax to: 660-826-5154 Email rpmoutreach@hotmail.com
In order to be considered for one of the homes you must have an entrance questionnaire submitted to
us and processed with us and our local Probation and Parole office. Our response to you should not
take any longer than 30 days. In some cases we can respond faster but it must be done through your
caseworker.
PROCEDURE FOR ENTRY
“Come to Me all that are heavy burdened, and I will give you rest.” Matthew 11:28
The RPM program is a voluntary one. Applications will be accepted only from people who are
committed to a life change.
Applicants must be physically able and mentally stable to participate in all work and living
situations.
In the event of bed unavailability, applicants should contact our office every week or two to
determine program availability.
No person will be admitted to the program that is currently taking psychotropic medications.
Applications from sexual and violent offenders will not be accepted.
To enable RPM to continue to provide this program and accommodations to people seeking help, a program fee
will be required from each resident. Residents are given 2 weeks to find employment. The RPM program will
assist you in finding work but it is your responsibility to continue to apply for jobs until work is found. A job
search log must be filled out daily until work is found. We do have work resource helps and relationships with
several in the area. Once you find employment or the beginning of the third week whichever comes first,
resident is required to pay a program fee of $125.00 per week. The program fee helps cover the costs of
accommodations, food, laundry, phone, television, utilities, access to approved social services, auto expenses,
personal storage of goods (limited) and local transportation to church, treatment centers and social services.
Residents are responsible for the purchase of toiletries, personal items, and clothing.
All policies are subject to change according to the circumstances, time, place, and attitude of the resident.
This will be at the discretion of the Program Directors.
I have read the entire RPM agreement contained herein. I understand the terms and conditions of the RPM
program that are detailed in the RPM application agreement. I agree to follow the terms and conditions of the
RPM program. I understand that I am a client of the RPM program. My weekly fee is a program fee and not a
tenancy agreement. I have completed the entrance questioner to the best of my ability.
I understand & agree that any information knowingly given to be false is grounds for immediate expulsion from
the program. I further agree to review the entire Program Manual and abide by it’s provisions. I further agree
to commit to the program length of 6-12 months and understand that leaving prior to the agreed upon
term without just cause may be a Parole Violation.
Client Agrees:
Signed this date: _____________________________________
Print name:__________________________________________
Signature ___________________________________________
For Office Use: Date Appl. Received:__________________________Outdate:_____________________sent for P&P check:______________________
Date Responded to:___________________ Response:____________________________ If accepted date to come:______________________________
P&P Background Check:______________________________________________________________________________________________________
__________________________________________________________________________________________________________________________