Apply for our Program Intake Form NameDate of Birth PhoneEmail What agency or person referred you to BRM?How many children do you have?What are their ages and date of birth?Do you currently receive child support? Yes No Where are you currently living?Have you ever lived in transitional housing? Yes No Are you currently working? Yes No If so, what do you for work? If no, when was the last time you were employed?Do you have a GED or High School diploma? GED High School diploma Neither Do you have a post high school education/ certifications? Yes No If you have certifications, what are they?Are you single, married, or separated? Single Married Separated Are you pregnant? Yes No Are you disabled? Receiving SSI?Are you a Brevard County resident? Yes No Are you a US citizen? Yes No Do you have any legal matters, arrests, convictions currently or in your past? If so, explain?Are you currently in a domestic violence situation?Have you ever been in a domestic violence situation?Do you have a restraining or no contact order? Restraining Order No Contact Order Neither Have you ever had an open DCF case? Yes No Do you or your children have any medical issues?Are you currently taking medication? If so, please explain.Are you currently using any illegal or controlled substances?Are you a smoker? Yes No Are you willing to quit? Yes No Do you currently have a Driver's license?Do you have a car? Yes No Do you have a car payment? Yes No Do you have current car insurance? Yes No Why do you think you need this program?What are you goals while in the program?
Brevard Rescue Mission
Brevard Rescue Mission