ENGAGEMENT FORM

Christ Kitchen is a job-training project providing work, instruction, discipleship, support, and fellowship for women living in poverty in the Spokane area. Through the production and sales of gourmet dried food products and catered meals, this project enables women to work, become employable and, eventually, support themselves and their families without reliance on government programs or destructive relationships.

Christ Kitchen recognizes the myriad issues that make employment and self-sufficiency difficult for women living in poverty. We offer a work setting in which any willing woman can gain skills and competencies that, in turn, improve her confidence and self-image. Helping low-income women learn the love of Christ and achieve emotional and mental stability as they become self-reliant, stable workers and citizens is the goal of our growing community. We are a place of hope and healing in the name of Jesus Christ.

Please provide the following information and answer the questions below. Please note: any information you provide here is protected as confidential information.

Name
Date of Birth:
Marital Status:
Current Address
Leave Message?
Leave Message?
Okay to email you?
*Please note: Email correspondence is not considered to be a confidential medium of communication
Are you currently taking any prescription medication?
Are there any addictions that you are currently struggling with?

GENERAL PHYSICAL AND MENTAL HEALTH INFORMATION

How would you rate your current physical health?

GENERAL PHYSICAL AND MENTAL HEALTH INFORMATION

In the section below, indicate whether there is a family history of any of the following conditions. If yes, please identify the family member’s relationship to you in the space provided (e.g., father, grandmother, uncle, sister, etc.).

Alcohol/Substance Abuse:
Anxiety:
Depression:
Domestic Violence:
Eating Disorders:
Obsessive Compulsive Behavior:
Schizophrenia:
Bipolar:
Suicide Attempts:

ADDITIONAL INFORMATION

Are you currently employed?
Do you consider yourself to be spiritual or religious?