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Rise Program Application
Contact Information
First Name
Last Name
Birthdate
Month
January
February
March
April
May
June
July
August
September
October
November
December
Date
1
2
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31
1912
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1917
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1919
1920
1921
1922
1923
1924
1925
1926
1927
1928
1929
1930
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1932
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1939
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1941
1942
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1959
1960
1961
1962
1963
1964
1965
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1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
Year
1980
1981
1982
1983
1984
1985
1986
1987
1988
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1990
1991
1992
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1994
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1996
1997
1998
1999
2000
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2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
2025
Gender Assigned at Birth
Male
Female
Ethnicity
Black / African American
Hispanic / Latino
White
Asian
Native American / Indigenous
Middle Eastern
Pacific Islander
Other
Please make sure to include a phone number or email address so we can get in touch with you. Without contact information, we won’t be able to follow up with you.
Phone Number
Email
Preferred Contact Method
Email
Phone Call
Text Message
General Questions
Have you ever served in the military?
Yes
No
Which branch of the U.S. military did you serve in?
Army
Air Force
Coast Guard
Navy
Marine Corps
Space Force
Year started
Year ended
Approximate date homelessness began
Have you received any services from Sunshine Rescue Mission before? If so, when was the last time?
0-6 Months Ago
6 Months - 1 Year Ago
1 Year -5 Years Ago
5 Years Ago +
None
Are you currently in Flagstaff?
Yes
No
Where did you stay last night?
How did you hear about the RISE Program?
Referral - Court System
Referral - Housing Agency
Referral - Incarceration Reentry
Referral - Substance Abuse agency
Referral - Sunshine Rescue Mission Staff
Referral - Thrift Store
Referral - Other
Walk in
Internet
Friend
Flyer posted around town
Church
Please list the name of who referred you
Have you previously participated in a residential program lasting longer than 90 days?
Yes
No
Did you complete this application with the assistance of a RISE Facilitator?
Yes
No
If yes, please provide the name of the RISE Facilitator
Is a case worker from another agency referring/ assisting you with this application?
Yes
No
Does the Sunshine Rescue Mission have your permission to contact your case worker?
Yes
No
Name of your case worker
Name of Agency
Phone Number
Email
RISE Program Questions
Have you ever experienced challenges with substance use?
Yes
No
Are you ready to commit to living in a sober environment?
Yes
No
Are you prepared to engage in regular check-ins with a staff facilitator?
Yes
No
Are you ready to invest 20–30 hours per week in activities focused on your personal growth?
Yes
No
Are you willing to receive feedback and guidance?
Yes
No
Are you open to contributing to daily tasks within the community?
Yes
No
Are you willing to check in every night as part of the requirements?
Yes
No
Have you participated in any programs, services, or support systems in the past (such as recovery programs, housing programs, therapy, job training, or reentry support)?
Recovery & Sobriety Programs
Mental Health Programs
Transitional & Reentry Programs
Shelter or Homeless Services
Life Skills & Workforce Development
Veteran Services
Other
None
Please specify how long you attended each program and if you completed the program
The RISE Program exists within a Christian community-environment. Will you respect the programs faith-based guidelines even if you don't share the same beliefs?
Yes
No
For SRM Staff:
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