Please select the option that applies to you:
Addictions Victorious GroupResidential ProgramNon-Residential Program/Care Group

MINISTRY REPRESENTATIVE'S PERSONAL INFORMATION

Your Name*

Email*

Cell Phone Number*

MINISTRY INFORMATION

What is the name of the ministry, church, or program with which you serve?*

What is your role or title in the ministry with which you serve?*

What country is the ministry located in?*
U.S.A.Other

If other, Please type country

Ministry's Street Address with City, State, & Zip*

Ministry Phone Number (if any)

MINISTRY REPRESENTATIVE'S SPIRITUAL BACKGROUND

Briefly describe your conversion to Christ*

List the local church you attend. Are you a member?*

Local Church Address*

Church Denomination*

Describe why you are passionate about discipling addicts.

Briefly tell us how you describe the problem of addiction.

How do people become addicts? What are some underlying issues and causes?

What is the solution for addiction?

What curriculum or Bible study material(s) do you currently utilize in your program, ministry, or church? What do you like about them?

Are you already Commissioned by The Addiction Connection?

SPIRITUAL REFERENCES

Please list three (3) Spiritual References below. List the FULL NAME, MINISTRY/CHURCH, EMAIL, and CELL PHONE NUMBER of each reference below. Also, be sure to notify your references that The Addiction Connection will be contacting them.