MISSIONGATE AFTERCARE PROGRAM

Trish Mathes Executive Director

PO Box 6644

Chesterfield MO 63006

APPLICATION

St. Louis Guest Homes: _________     Fort Good Shepherd Ranch: _________

(Please answer all questions honestly and completely)

GENERAL INFORMATION

Personal:

Last Name:______________________ First Name: ______________________ Middle: _____

Institution: ___________________________________________ ID#: ____________________

Home

Address: ___________________________City:______________ State: _____ Zip: _________

Former

Address: ___________________________City:______________ State: _____ Zip: _________

Date of Birth: ______________ Social Security #: ___________________ Marital Status: _____

Sex: _____ Height: __________ Weight: __________ Disability: _________________________

Expected Release Date: ____________ Explain: ______________________________________

How did you learn about Mission Gate?

_____________________________________________________________________________

_____________________________________________________________________________

If accepted, what would you like to accomplish during your year at Mission Gate?

_____________________________________________________________________________

_____________________________________________________________________________

Referral

Last Name:______________________ First Name: ______________________ Middle: _____

Home

Address: ___________________________City:______________ State: _____ Zip: _________

Nearest Relative:

Last Name:______________________ First Name: ______________________ Middle: _____

Home

Address: ___________________________City:______________ State: _____ Zip: _________

(Personal Reference Form is Attached)

 (Page 1)

SPIRITUAL INFORMATION

Check the description below that best summarizes your relationship with Jesus Christ:

__________ This is the first time I have thought about it.

__________ I have thought about it but I am not sure that I am ready to make a decision.

__________ I have not made a commitment to Jesus, but I am ready to do so now.

__________ I think I have made a commitment to Jesus, but I am not sure.

__________ I know I made a personal commitment to Jesus on this date: __________________

Briefly explain this commitment: ___________________________________________________

_____________________________________________________________________________

What church did you attended: ___________________________ Pastor: _________________­_

What services have you attended while incarcerated: __________________________________

_____________________________________________________________________________

LEGAL INFORMATION

What crime are you serving time for: ________________________________________________

List all previous convictions:

Crime: _________________________ Institution: ____________________ Dates: ___________

Crime: _________________________ Institution: ____________________ Dates: ___________

Crime: _________________________ Institution: ____________________ Dates: ___________

Crime: _________________________ Institution: ____________________ Dates: ___________

Do you have any upcoming court dates? When: _______________________________________

Will you be released on:

Parole: _________ Probation: _________ House Arrest: _________ No Supervision: _________

Institutional Parole Officer:

Name: _________________________________________ Phone #: ______________________

Institutional Case Worker:

Name: _________________________________________ Phone #: ______________________

Will you be required to attend MERS or Gateway Free & Clean? Yes: _______ No: __________

Circle One: Level         1           2          3

Page 2

SUPERVISION INFORMATION

Chaplain:

Name: ____________________________________________ Phone: _____________________

Institutional Parole Officer:

Name: ____________________________________________ Phone: _____________________

Outside Parole Officer:

Name: ____________________________________________ Phone: _____________________

Next scheduled parole hearing date: ____________________

Outstanding warrants/charges: ____________________________________________________

EDUCATIONAL INFORMATION

Last grade completed: _________________                     GED Yes: ________ No: __________

If NO, do you plan to work on GED while at the Mission Gate:    Yes: ________ No: __________

College grade completed:     1     2     3     5          Graduate Studies: ______________________

Degrees or certificates earned: ____________________________________________________

_____________________________________________________________________________

HEALTH RECORD

Do you have any health problems present or past?                    Yes: ________ No: __________

What are they: ________________________________________________________________

_____________________________________________________________________________

What medications are you currently taking: ___________________________________________

What medications have you taken in the past: ________________________________________

Are you HIV positive: Yes: _____ No: _______   Are you TB positive: Yes: ______ No: ________

List any disabilities: ______________________________________________________________

Are you receiving SSI:    Yes: ________ No: __________                   Amount:_______________

For what: _____________________________________________________________________

_____________________________________________________________________________

Page 3

COUNSELING NEEDS

For which of the following programs do you have a need?

Alcoholic Victorious:      __________        Victim of Sexual Abuse: __________

Drug Rehabilitation:       __________        Parenting Classes:        ___________

Sex Therapy:                 __________        Marital Counseling:        ___________

Financial Stewardship: __________        Personal Counseling:     ___________

Anger Management:     __________        Violent Behavior:            ___________

Have you ever been diagnosed with a mental disorder or learning disability? _______________

Are you currently taking medication for this disorder? __________________________________

Are you satisfied that this medication is helping this disorder? ___________________________

Please explain answers to above questions:

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

OFFICE USE ONLY

Application mailed: __________ Application returned: __________ Accepted: Yes____ No ____

Comments: ___________________________________________________________________

Acceptance pending:

            Receipt of personal reference: __________   Date received: _________

            Receipt of drug release:          ___________ Date received: _________

Date home plan investigated: __________ By whom: __________________________________

Date released from prison:     __________

Guest house/cabin: __________________________ In date: __________ Out date:__________

Pertinent Information: ___________________________________________________________

Parole Office: ___________________________________ Phone: ________________________

Page 4

MY CHRISTIAN TESTIMONY

(Must be completed by applicant)

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

DISCLAIMER

I ______________________________________, give Mission Gate permission to use my

personal testimony for publication or broadcast and I do hereby release and do save harmless

the Mission Gate, and it servants, from any and all claims based on the use of this material.

I furthermore consent and authorize that this material may be edited and may be utilized in any

way by the Mission Gate for any purpose that they desire for the ministry of leading lost souls to a saving knowledge of Jesus Christ.

                                                                                                            Date: ______________

                                                                        Signed: ________________________________

                                                                        Printed: ________________________________

If not signed, your testimony will be kept confidential.

Page 5

GUEST HOUSE AGREEMENT

I _______________________________________, understand that this application will be reviewed by the Mission Gate Guest House Committee and upon acceptance a copy will be given to my Guest House Supervisor.

I give Mission Gate my permission to contact any references or other persons or agencies they may choose for the purpose of making a decision on admitting me into their one year rehabilitation program and Guest House residency.

I affirm that the foregoing information is true and accurate to the best of my knowledge and belief.

Furthermore, if any information is deemed incorrect or untrue, or any rules broken, I understand that there will be immediate expulsion from the Guest House but not from the program and that my parole/probation officer and/or the courts will be fully informed.

I further understand that I am responsible for the replacement cost for any damages that I inflict upon Mission Gate guest homes or property.

I further understand that all household items and furniture belong to Mission Gate and any missing properties will be reported as a theft to the local police.

I thereby give Mission Gate my permission to release any and all information about me to whomever they deem necessary for the purpose of my progress in their program or for my total well-being of others in this reintegration process as they shall determine.

I further understand that I have no rights as a tenant or renter in the Mission Gate guest house as which I may reside and I understand that if requested to vacate, I will do so immediately.

I understand that the police authority will be called to assist if I do not leave immediately and voluntarily.

I further understand that any moneys that I may remit to Mission Gate are in reimbursement for the actual cost of maintenance, insurance, utilities and program supplies and do not constitute rent.

I have read the Guest House Agreement and agree to comply.

Signed Name:           _____________________________________ Date: ______

Printed Name:           _____________________________________

Page 6

PERSONAL REFERENCES

To the applicant:

Please have a social worker, chaplain, counselor or close relative fill out this form and return it to the Mission Gate. A final determination will not be made until this form is received. Please remember to sign the paragraph on the other side of this form.

To the reference;

(Applicant Name) ______________________________ has applied for admission to the Mission Gate Guest House and Aftercare Program. Please fill out the information below so that his/her application may be considered. Your honest and accurate answers will help us to best help him/her and o determine if our program is best suited for him/her. You have permission from the applicant to release any and all information that is requested on this form or that you deem beneficial to the Mission Gate in making their determination. Thank you in advance for this consideration and your prompt reply.

1. How long and under what circumstances have you known the applicant?

      _______________________________________________________________________

      _______________________________________________________________________

2. How would you describe your relationship with the applicant?

      _______________________________________________________________________

      _______________________________________________________________________

3. What is the applicant’s greatest strength and weakness?

      _______________________________________________________________________

      _______________________________________________________________________

4. Why should we accept or reject this applicant?

      _______________________________________________________________________

      _______________________________________________________________________

5. In your opinion, what is the most important counseling need?

      _______________________________________________________________________

      _______________________________________________________________________

6. What is the applicant’s relationship with Jesus Christ?

      _______________________________________________________________________

      _______________________________________________________________________

Comments:

_____________________________________________________________________________

_____________________________________________________________________________

Page 1

PERSONAL REFERENCE CONTINUED

Please rate the applicant on a scale of 1 (poor) to 5 (excellent)

General attitude:

Spiritual commitment:                            1          2          3          4          5          Don’t Know

Attitude toward authority:                        1          2          3          4          5          Don’t Know

Ability to handle stress:                          1          2          3          4          5           Don’t Know

Ability to get along with others:              1          2          3          4          5          Don’t Know       

Work habits:                                            1          2          3          4           5          Don’t Know

Neatness:                                                 1          2          3          4          5          Don’t Know

Personal hygiene:                                   1          2          3          4          5          Don’t Know

Honesty:                                                   1          2          3          4          5          Don’t Know

Christian experience:                              1          2          3          4          5          Don’t Know

Other pertinent information:                    

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

Reference Name:           _____________________________________________

Address:                       _____________________________________________

City:     ________________________________ State: _______ Zip: _________

Home Phone: ___________________________ Work Phone: ___________________________

I, (applicant) __________________________ give (reference) ___________________________

my permission to fill out this form honestly and return it to:

Mission Gate Prison Ministry

PO Box 6644

Chesterfield MO 63006

Signed: _________________________________________________ Date: ________________

Page 2

GUEST HOUSE GUIDELINES

(Please keep this copy for yourself)

General Information:

Mission Gate is a Christian organization founded in 1985 that works in prisons and jails throughout Missouri, Kansas and Illinois that provides Bible studies, one-on-one counseling and worship services and worship services. Over 140 area churches participate with upwards of 300 field volunteers and 10 staff positions.

The Guest House and Aftercare Program is available for one to two years. The Ministry owns 5 homes in south St. Louis City and 100 acres with 30 cabins and 3 bunkhouses in Cuba MO., providing safe housing for up to 80 former inmates combined. An in-house supervisor and resident assistant runs each, overseen by our professional staff. An in-house supervisor is a respectable Christian leader who has been free from drugs and alcohol for a minimum of five years and who is not on probation or parole. They also assist in the spiritual day-to-day guidance of the residents. A resident assistant is a resident who has graduated from the one-year program and has remained drug and alcohol free. His job is to report to the Guest House Committee any infractions of the rules. The Guest House Committee is a team of staff and volunteers who oversee the day-to-day activities of the Guest Homes as well as the welfare of the residents.

The Aftercare Program conducts the following classes:

• Anger and violent behavior management.
• A variety of life skill development classes.
• One-on-one and group counseling.
• Bible studies and worship services.
• Sexual abuse recovery.
• Financial stewardship.
• Parenting classes.
• Marital counseling.

Program goals and objectives are individualized to meet the resident’s needs. Each person’s strengths, weaknesses, and identified problems are taken into consideration. Networking with other services and agencies are an important part of our efforts to advance toward the achievement of establishing goals. Reporting to Probation and Parole, the Courts, or Division of Family Services is a routine part of the effort to provide the best service to the resident, society and the community by providing and maintaining a drug and alcohol free environment.

Page 1

GUEST HOUSE GUIDELINES CONTINUED

Purpose:

The Guest House is a residential ministry of the Mission Gate. It is the desire of the ministry to assist ex-offenders, the homeless and graduates of drug and alcohol treatment centers in their reintegration into the local community as strong and productive Christians. Certificates of recognition are issued after 4 months, 8 months and one year completion dates.

Goals:

Short Term: The goal of ministry is to provide a potential one to two years of residential aftercare for Christian growth, fellowship, counseling needs, and living skills.

Long Term: The goal of ministry is to re-integrate the resident into the community and a local Bible teaching church upon graduation from the Aftercare Program. It is our objective that the resident will be spiritually, emotionally, physically, financially, and vocationally equipped to graduate from the program within one year. A second year of discipleship training is available to those approved by the Guest House Committee.

Admissions:

An applicant must be referred to the Guest House Committee by a Mission Gate volunteer, area ministry leader, case worker, institutional activities coordinator or parole or probation officer, or Chaplain who has personally known the applicant while incarcerated. Upon written request, an applicant will be sent directly to the inmate. A fully completed application must be submitted to the Guest House Committee and approved prior to admission. All information received is kept on a confidential basis unless otherwise released by the applicant for a specific purpose.

Resident Responsibilities:

• You must attend and be active in a local church and provide a church bulletin each Sunday as evidence of your having attended the service.
• You have a 10 PM curfew the first 4 months with will be extended to 11 PM and then weekend furloughs will be considered.
• You must attend all classes and counseling sessions through the week.
• You must provide $85 per week maintenance fee from the second week.

Personal:

• You must maintain a clean and personal appearance honoring Christ.
• No body piercing, including tongue, eyebrows, navel or nose allowed.
• Satanic body tattoos must be covered or removed.
• Two house of work service is required each week as assigned.

Financial:

01.     You must obtain full-time employment.

02.     You must be current on paying your maintenance fee each week.

03.     You must pay by cash or money order only.

04.     You must pay for any damage you have caused to property.

Violation of these rules will result in expulsion from the program!

Page 2

Applicant’s Questions

Include these with your application:

01. _____________________________________________________________

02. _____________________________________________________________

03. _____________________________________________________________

04. _____________________________________________________________

05. _____________________________________________________________

06. _____________________________________________________________

07. _____________________________________________________________

08. _____________________________________________________________

09. _____________________________________________________________

10. _____________________________________________________________

11. _____________________________________________________________

12. _____________________________________________________________

Signed: _________________________________________ Date: ___________

Page 4

Memorandum of Understanding

This is my personal statement that I, ______________________________ do

understand that the Mission Gate Aftercare Program is a one year program.

If accepted, and approved by Parole and Probation, I most certainly do

promise to stay for the full year and I also fully understand that if I do not

complete a full year, I will likely be required to be on an electronic

monitoring device, if approved by Parole and Probation, or if not approved

and I leave anyway, I fully understand that I will most likely be returned to

an honor center and my parole may be revoked.

Signature: ________________________________ Date: ________________

Printed Name: __________________________________________________

Witnessed:     __________________________________________________

Title:               _____________________________ Date: ________________

Page 5

Mission Gate Prison Ministry

PO Box 6644

ChesterfieldMO63006

FORTGOOD SHEPHERD RANCH

RULES AND PROCEDURES

(Keep and learn these well)

01.   There is zero tolerance for drugs and/or alcohol. All residents must be drug free and willing to submit to a urine test and/or breath test as staff deems necessary. No weapons or pornography is allowed.

02.   There are three mandatory classes you must attend that meet at the Lodge. These classes meet on Mondays at 5:30 PM, Thursdays at 6:30 PM and Fridays at 5:00 PM. Also there are special counseling sessions at the Lodge at assigned times.

03.   All residents must attend a local evangelical church of their choice and weekly attendance is required at their Sunday morning service unless special permission is granted. It is your responsibility to find a ride to church.

04.   Program/maintenance fees must be paid every Friday in cash or money order.

05.   You must stay on the property. Surrounding property is off limits!

Any violation of the above 6 rules

is cause for dismissal form the Aftercare Program!

(You will be given 48 hours to find other arrangements for your housing.)

• You are not allowed any overnight stays away from the Fort.
• You may request one weekend per month with family after 4 months.
• You may only have permission to stay overnight with immediate family.
• You must have request form filled out at least one week in advance.
• You are responsible for having someone pick you up and return you if you don’t have your own transportation.
• You may not be in arrears on your maintenance fee to leave overnight.
• You are making a commitment of one year to complete this program. If your date falls between the 1^st and 15^th, you may leave as of the first of your graduating month. If your date falls after the 15^th, you must stay until your graduation date. Some people feel the need to stay more than a year and that is possible and will be considered on a case by case basis. If you are approved to stay past your year, you must continue to attend all the classes as well as the other commitments of the program.
• You are not allowed to operate/drive another resident’s vehicle.
• You are not allowed to display any body piercing or earrings.
• You must have Reyna make arrangements to be an authorized person on your land-line phone account. This is to protect you and allow the next man to have a phone in his cabin.
• Satellite TV cannot have any movie channels such as: TMC, Showtime, Startz, Cinamax. etc. No “R” rated movies. If adult TV is detected on your TV , you will be discharged from our program. This is serious.

Page 1

Rules and Procedures Continued:

• No pets in addition to our dogs and cats at the ranch will be permitted.
• You will live in a bunkhouse for at lest 30 days and then you will be allowed to move to a single man cabin as your seniority allows and there is availability during your stay. You will be provided bedding (sheets, pillow, blankets, etc.) while in the bunkhouse but by the time you move into your own cabin you will be responsible for purchasing your own bedding. All ministry bedding stays in the bunkhouse.
• You must keep your living area clean at all times which includes your fed being made while you are not at home. If this is not adhered to, financial fines will be imposed on a case by case basis. Also, if you don’t keep you cabin clean you will loose your privilege to a cabin and return to a bunkhouse for 90 days, after which you will be placed on the list for a cabin. There is NO SMOKING allowed in any building or in any FGS vehicle. You are to dispose of cigarette butts in a designated container only. Do not throw them on the ground or dispose of them in a toilet.
• You are required to provide a minimum of 2 hours per week to help out with the maintenance/up-keep of FGS property as assigned. It is YOUR RESPONSIBILITY to seek out your team leader and find out what your work assignment is for the week. Failure to complete your 2 hours will result in a $20 fine due at the time you pay your maintenance fee on Friday night.
• If you are on parole/probation or other self-help groups, you are prohibited from associating with anyone on parole/probation except on campus, at work or in church. Your blanket of protection ends when you leave the FGS property.
• You may not make any major purchases from another resident; this includes, but is not limited to, vehicles. Also, you may not employ anyone in the program to do mechanical work on your vehicle for money.
• You are not to lend/borrow money to/from anyone in the program.
• You may not have in your possession on FGS property a vehicle unless you have a valid driver’s license and title the vehicle in a timely manner. You may only have 1 vehicle at a time on FGS property.
• If you leave FGS for any reason, you have 48 hours to remove your personal property from the premises. A staff member must be present when you are removing your property. After 48 hours, we are not responsible for your property and any remaining property will be disposed of accordingly. During the 48 hours, if you are under the influence or are in possession of any drugs and/or alcohol, you will be asked to leave immediately.
• During your first 30 days, you CANNOT go canoeing with any other FGS resident. After the 30 days, you must obtain permission from your Parole Officer along with permission from the FGS staff. This will be evaluated on a case by case basis.

Page 2

Rules and Procedures Continued:

• There is zero tolerance for stealing. If you are found with anything in your possession and/or your living quarters that does not belong to you, you will be asked to leave the ranch immediately.
• Some cabins have computers in them. If your cabin has one, you may use that computer during your stay at the Fort. If you leave without graduating from the program, the computer remains as FGS property.
• All mail is picked up on a daily basis by staff and is distributed as soon as possible. Do not remove ay mail or go through the mail in the mail box at any time. The only time you may open the mail box is to mail a personal letter. Be sure to lift up the red flag for the mailman to respond.
• If you leave the Fort and go back to prison/jail, you will not be eligible to re-enter the Mission Gate Aftercare Program.
• If you are place on restriction for any reason, the following applies to you:

01.   You may leave up to 30 minutes prior to your work start-time and you must return within 30 minutes of your quitting time.

02.   You must be employed full-time and my not work any side jobs.

03.   You may not attend any church service except Sunday morning.

04.   You may only go to the store with staff approved drivers at their convenience.

Please keep in mind, these are procedures are not all inclusive but should give you enough information to start on your journey to building a new life that is acceptable to our Lord.

Always keep in mind that you are a guest of the Fort.

This is a privilege not an entitlement.

First program fee payment due on: Date:___________

Emergency contact name: _________________________________________

Contact phone _____________________________

Address: _______________________________________________________

Your signature: _______________________________ Date: _______________

Print your name: ___________________________________________________

Page 3

MISSIONGATECHRISTIANCENTER

POBOX 6644

CHESTERFIELD MO 63006

Trish Mathes

Executive Aftercare Director

Crystal Goings

St. Louis Guest Home Director

Rick Mathes

FortGood Shepherd Ranch Director

Home Office:           636-391-8560

Aftercare:                 636-391-8832

Ranch:                      573-885-3308

Web Site:                  www.MissionGateMinistry.org

Email:                        MissionGateMinistry@msn.com

                                    FortGoodShepherd@aol.com

Fax:                            636-391-8811

Rick Mathes cell:    314-602-0117

Emergency Phones:

St. LouisMO            314-322-3775

Cuba MO                  573-259-2580

When you arrive at your destination, St. Louis or Cuba, just call the emergency numbers and we will pick you up and bring you to your new residence.

We will connect you with your parole or probation officer at the soonest possible convenient time.

We are automatically approved as a aftercare facility by the city, county, state and federal parole and probation departments of each respective jurisdiction.

DON’T WORRY!

Page 6

MISSIONGATECHRISTIANCENTER

POBOX 6644

CHESTERFIELD MO 63006

Trish Mathes, MA

Executive Aftercare Director

Crystal Goings

St. Louis Aftercare Director

Home Office: 636-391-8832

Fax: 636-391-6611

Email: MissionGateMinistry@msn.com

(For Office Use Only)

Resident Name: _________________________________________

Date of Birth: _____________

Social Security #: ___________________________

Assigned Housing Unit: _________________________________

Date of Test:         Adm. By:               Pos.                    Neg.                   Substance:

__________          __________          __________      __________      __________

__________          __________          __________       __________       __________

__________          __________          __________       __________       __________

__________          __________          __________       __________       __________

__________          __________          __________       __________       __________

(For Office Use Only)

01.     Cooperate with staff/in-house supervisor and answer all questions honestly.

02.     As a condition of residency, resident is subject to random drug/alcohol testing.

03.     Resident is advised that failure to submit to testing or tampering with testing shall be considered the same as a positive test.

04.     Any positive results can lead to immediate termination from residency but not to the aftercare program.

05.     Mission Gate will inform probation/parole officer of all test results and judges in the case of residency to Mission Gate mandated by court.

Acknowledgement:

I the undersigned, have read and/or have had read tome the above information and understand these instructions. I understand that the court and/or probation & parole will be informed if I fail to cooperation or if test results are positive.

In House Supervisor: __________________________________________ Date: ___________

Signature of Resident: _________________________________________ Date: ___________