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    Starfish Program

A Mentoring  and Coaching Program for Women who have experienced domestic violence or sexual assault and  want 

t​o live their best lives

                  Starfish Program Application

To be completed by the applicant*

Please answer all questions to the best of your ability. Use additional paper if necessary.

Applicant

name:____________________________________________

Address:__________________________________________________

_________________________________________________________

How long have you lived there?_____________________

Future address if planning to move:______________________________

__________________________________________________________

Daytime phone:__________________                       Evening phone:____________

Email address:_______________________

May we contact you by phone: yes or no                     by email: yes or no

 Or mail: yes or no Which is your preferred method of contact?_________________

Best time to contact you:_________________________________________________

Applicant Birthdate:________________           Number of Children:_____________

Ages of Children:__________________           Other dependents in your care:___________

Other adults in your household:___________________________________________

Monthly Income: Indicate gross or net

Amount:___________              Source:_______________

Amount:___________              Source:_______________

Amount:___________              Source:_______________

If you are currently employed:

Place of employment:___________________________________________

Job position/title:_______________________________________________

*Your employer will not be contacted without your permission

Do you have a current open OFP or legal proceedings?________________________________

How did you hear about the Starfish Program?________________________________________

_____________________________________________________________________________












*What do you feel are your greatest strengths (where are you the most self sufficient)?

What area of your life do you want the most help with?

Personal Goals and plan for participation


·                     Tell us about your short and long term plans for your life.

·                     What steps have you already taken toward meeting those goals?

·                     What is your reason for requesting to be in this program?

·                     At this time, how do you feel you would like to spend the money received should it be available?

·                     Are you willing to attend group consistently and meet regularly with a Mentor to improve your skills and self-                              sufficiency and commit to a solid growth plan?

·                     What are the things you would most like to change about yourself?

·                     Describe your support network – those in your life whom you trust and who trust you.

·                     Describe your readiness to do weekly homework and to take action to implement new tools, knowledge and                                  resources into your life.

·                     Are you ready and willing to be personally challenged and held accountable? You must be sure you are ready!                                Old,  -defeating behaviors will be challenged strongly.

·                     What fears, if any, do you have about participating in the Starfish Program?

·                     Share any other information you would like us to know:

·                  What questions do you have about the program?

By signing this application I agree that the information provided in this application is true and factual.

__________________________________                   ____________________________

Applicant                                                                                   Date

*All information provided is private and confidential. The Starfish Program will not disclose any personal information without written consent.

 Print and complete. Send completed application to

Starfish Program

215 North Benton Drive

Sauk Rapids, MN 56379