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573-248-6323 | 1732 Hope St, Hannibal, MO

HARVEST OUTREACH MINISTRIES

Please complete both pages of this application.

Application for Membership in

The Harvest House

Gender (check box that applies)
Are you an alcoholic?
Yes
No
Are you an Addict?
Yes
No
Do you want to stop using drugs and alcohol?
yes
no
Do you have a sponsor?
Yes
No
Will you attend church services?
Yes
No
Are you employed?
Yes
No
Are you getting disability or other non-job related income
Yes
No
Do you have a medical doctor?
Yes
No
Do you have a mental health provider?
Yes
No
Do you take prescription drugs?
Yes
No
Have you ever been in a treatment facility for drug/alcohol addiction?
Yes
No
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