A Mentoring and Coaching Program for Women who have experienced domestic violence or sexual assault and want
to 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.
How long have you lived there?_____________________
Future address if planning to move:______________________________
Daytime phone:__________________ Evening phone:____________
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
If you are currently employed:
Place of employment:___________________________________________
*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.
*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
215 North Benton Drive
Sauk Rapids, MN 56379