Resident Application Packet — The Well of Columbia

Personal Information

Full Name

Date of Birth

Age

Phone Number

Address

City / State / Zip

Where are you currently incarcerated, and for how long?

Marital Status

Single Married Divorced Widowed

Emergency Contact

Full Name

Relationship

Phone Number

Children (If Applicable)

Name

Age

M/F

Custody Status

Status of Your Children (CPS, Foster Care, etc.)

Spiritual Background

Salvation Testimony

Current Daily Spiritual Discipline

Reason for Applying to The Well

Personal Background

Relationship with Parents

Struggles with Authority? Yes No If yes, please explain:

Legal Information

Arrested or Convicted? Yes NoIf yes, explain:

Active Warrants? Yes NoIf yes, explain:

On Parole? Yes NoIf yes, explain:

How long have you been in prison?

What are your charges?

What classes have you completed in prison?

Past Financial / Employment History

Outstanding Financial Obligations? Yes No

If yes, please describe (Child Support, Utilities, Fines/Fees)

Past Employment

Medical Information

Special Accommodations Needed? Yes No

If yes, please describe

Under Doctor Care? Yes No

Medications? Yes No

If yes, please list medications

Mental Health Diagnosis? Yes No

Substance Abuse History? Yes No

Previous Treatment Program? Yes No

If you answered yes to any of the above, please provide details

References

Name

Phone

Relationship

Vision for Your Life

How do you feel God is calling you to build your future in this season?

What kind of woman do you desire to become, and what does a life established in His presence look like for you?

Take your time and share your heart honestly. We want to understand the vision God is placing inside of you.

Program Expectations & Commitments

By applying to The Well, you acknowledge and agree to the following:

You are seeking a Christ-centered environment focused on healing, discipleship, and personal growth.
You understand that The Well is a structured program with expectations regarding participation, behavior, and accountability.
You commit to engaging fully in classes, counseling, church involvement, and daily spiritual disciplines.
You agree to respect staff, leadership, fellow residents, and the guidelines established for your safety and growth.
You understand that acceptance into the program is based on prayerful consideration by The Well leadership.

Application Agreement

I affirm that the information provided in this application is true and complete to the best of my knowledge. I understand that providing false information may result in denial of admission or dismissal from the program.

Full Name

Signature

Date

The Well of Columbia, Inc.

Personal Information

Emergency Contact

Children (If Applicable)

Spiritual Background

Personal Background

Legal Information

Past Financial / Employment History

Medical Information

References

Vision for Your Life

Program Expectations & Commitments

Application Agreement