Apply - Come As You Are Ministries Steamboat Springs Colorado

Are you ready to…

Before filling out the application below, we ask that you confirm your understanding of the CAYA expectations to ensure that you are a good fit for the program. Please be open in your answers.

I have a desire to change.

Fully agree

I am able to have a 30 day black out with zero contact with anyone outside of our program during this time.

Fully agree

I am willing to have very limited access to the internet, and zero access to my personal phone for a period of time which will be based on my success in the program. (minimum 6 months)

Fully agree

I am willing to have very limited access to family and friends for the duration of the program. I am also willing to have only a 10 minute monitored weekly phone call and monitored letters for a time period that will be based on my success in the program.

Fully agree

I will have zero communication with anyone associated with my addiction.

Fully agree

I am ready to attend and participate in Bible classes, parenting classes (if applicable), budgeting classes, and weekly addiction meetings.

Fully agree

I am able to take care of ALL outstanding bills and debts before entering our program or after the 12 month period.

Fully agree

I will give up all tobacco products.

Fully agree

Prescription medications for mental health (antidepressants, adderall, psych meds) are not allowed. (If applicable) I am willing to get tapered off of these medications and be detoxed from them before entering CAYA.

Fully agree

I am willing to be randomly drug tested throughout the duration of the program.

Fully agree

I will give up dating and communicating with men for the duration of the program.

Fully agree

To fund CAYA, residents participate in a cleaning / work program throughout the week. I am able and willing to work 30-40 hours a week.

Fully agree

I will show all staff, volunteers, and other CAYA residents respect, even when I disagree with them.

Fully agree

Why do you want to attend CAYA? Please share your story in detail of how you got to today.

What are your goals in attending CAYA over the next 12 months? What do you hope will happen?

Application: About You

First Name*

Last Name*

Email*

Phone Number*

SSN #*

Age*

Date of Birth*

Physical Address*

City*

State*

Zip Code*

Do you have insurance?

Have you been to treatment before?*

Explain

What is your addiction?*

How long have you been in addiction?*

Addiction History: List all past and current drug use (including alcohol), listing drug of choice first. Substance, Length of use, Time period, Quantity:*

Are you currently taking any prescription medications? If so, list them.*

Do you have any upcoming court dates?*

Yes
No

If you entered yes, where are your court dates?

County

State

Are you currently on parole or probation?*

Yes
No

If you entered yes, where are your court dates?

County

State

Criminal History: List all convictions, with the most current first. Date, charge, sentence, time served.

Do you have any previous misdemeanor or felony charges?*

Yes
No

If yes, please explain

Do you have any previous violent charges?*

Yes
No

If yes, please explain

Do you have any previous sexual abuse charges?*

Yes
No

How did you hear about us?*

Do you have any medical conditions?*

What is your spiritual history and/or views on God?*

By checking “yes”, I agree that I have answered all statements truthfully to the best of my ability.*

Yes, and i am ready

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CAYA Application

Are you ready to…

Application: About You