Name
*
First Name
Last Name
Email Address
*
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Home Phone
(###)
###
####
Work Phone
(###)
###
####
Weight
Height
Hair Color
Eye Color
Social Security Number
Age
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
38.
39.
40.
41.
42.
43.
44.
45.
46.
47.
48.
49.
50.
51.
52.
53.
54.
55.
56.
57.
58.
59.
60.
61.
62.
63.
64.
65
Driver License Number
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Status of License
Valid
Expired
Suspended
N/A
Emergency Contact
First Name
Last Name
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Home Phone
Country
(###)
###
####
Work Phone
(###)
###
####
Relationship
Name (of referral)
First Name
Last Name
Address (of referral)
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone (of referral)
(###)
###
####
Relationship
Are you on probation?
Are you on parole?
Probation / Parole officer name
First Name
Last Name
Probation / Parole officer phone #
(###)
###
####
Public Defender / Attorney name
First Name
Last Name
Public Defender / Attorney phone #
(###)
###
####
Do you have any of the following that are pending?
If so, explain.
Are you legally mandated to participate in a drug treatment program?
If so, explain.
Method of reporting
Comments / Instructions
Have you ever served in the US Armed Forces?
Date of entry
MM
DD
YYYY
Date of discharge
MM
DD
YYYY
Branch of service
Rank attained
Type of discharge
Are you eligible for VA medical benefits?
Yes
No
Unknown
Parents Marital Status
Married
Divorced
mom deceased
dad deceased
Fathers Name
First Name
Last Name
Occupation
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Mothers Name
First Name
Last Name
Mothers Occupation
Address 4
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Are you adopted?
Age at adoption?
Where you raised by someone other than your parents?
If yes, who?
Describe your relationship with your parents when you were a child.
Describe your relationship with your parents now.
What is your mom, dad, or legal guardian's occupation?
Check any of the following words that best describe you now:
Are you unsure which words best describe you?
Yes
No
Is it easy for you to express your feelings? Please explain
Do you enjoy being with other people or would you rather be alone? Please explain
Marital Status / Intimate Relationship History
single
married
separated
divorced
remarried
widowed
List your present living arrangement (check all that apply)
If other please specify
If you are, or have been married, please list: (Start with your most recent marriage)
Current spouse's name
First Name
Last Name
Current spouse's occupation
Current spouse's phone #
(###)
###
####
If you ar married, describe your current relationship with your spouse
List the names and ages of your children (if you have children)
Describe any positive or negative aspects of your relationship with your children:
Describe any problems or concerns related to your relationship with your spouse:
Have you been sexually abused? If so, when and by who?
How old were you?
Were there multiple instances?
Once
Several times
Ongoing
Do you still have contact with this person?
Yes
No
To your knowledge, has anyone in your family ever been sexually abused?
Yes
No
By who?
When?
Do You Have Insurance?
Yes
No
Have you ever received psychiatric care? If yes, explain
Insurance Company (if you have insurance)
Policty Number (if you have insurance)
Have you ever struggled with the following?
Allergies? If so, explain.
Are you receiving medical care?
If yes, eplain. (Also explain any serious medical problems including ailments, injuries, handicaps or dental problems)
Are you on any prescribed medication including psychiatric?
If yes give name of medication and reason for prescription.
Do you have any special diet requirements?
If yes, explain.
Have you ever experienced or presently have a physical ailment, injury, or handicap that would prevent you from performing manual, work related tasks while enrolled in Teen Challenge?
If yes, explain.
Do you smoke or use tobacco in any form?
If you did smoke but quit, when did you quit?
Age at which you first started smoking/using?
Amount you are currently smoking/using per day?
Teen Challenge has a no smoking or tobacco use policy. Are you willing to abide by this policy?
To the best of your knowledge, which of the following substances has the applicant used?
Currently using?
Yes
No
Frequency of use (once, few times, several times, frequently, regularly)
How was it administered? (iv, smoked, etc..)
If applicable give specific name of drug
Date of charges
What were/are the charges?
Were you convicted?
What was the sentence?
How much time in jail did you serve?
Were alcohol or drugs involved?
Explain any circumstances you think are important
Do you have any outstanding debts, including child support?
Yes
No
If so, list who is owed, for what and amount owed
Do you have a means to cover payments while you are in the program?
Yes
No
If so, explain.
Are you receiving any of the following?
welfare
disability payments
unemployment compensation
workman's compensation
other
If other, list.
Are you a Christian
Yes
No
I'm not sure
Explain your involvement with church and/or other religions or occult practices
Denominational preference
Describe your current spiritual condition
Have you been in any other programs (including Teen Challenge)?
Yes
No
Name of program?
Reason for entrance
Date you attended program
MM
DD
YYYY
Did you complete it?
Yes
No
Reason for leaving?
Which of the following have you personally experienced?
If other, specify
Explain those that you have experienced
Check all that apply
Have you ever engaged in homosexual activities? If yes, explain
Check all of the statements that are true in your life.
List highest grade that you have completed
Are you currently in an education program? If yes, name and city of school.
Are you receiving or have you received vocational training? If yes, list type of skill/trade, date of training, and if you received any certifications.
Can you read?
Yes
No
How do you rate your reading?
Good
Average
Poor
Can you write?
Yes
No
How do you rate your writing?
Good
Average
Poor
Describe your future educational goals and plans
Describe your future vocational training goals and plans
What is your vocational trade or profession?
How many jobs have you held in the last two years?
List your present employment status
Unemployment (Have not sought employment in the last 30 days)
Unemployment (Have sought employment in the last 30 days)
Employed part-time (Working less than 35 hours per week)
Employed full-time (Working 35 hours or more per week)
List your two most recent jobs (Start with your most recent)
List your current average monthly income
Describe your future occupational goals and plans
Have you ever experienced or presently have a physical ailment, injury, or handicap that would prevent you from performing manual work-related tasks while you are enrolled in Teen Challenge?
Yes
No
If yes, explain
Have you ever received mental health treatment? If yes, please explain
Have you ever though about suicide?
Are you currently thinking about suicide?
Have you ever attempted suicide?
Date of most recent attempt
MM
DD
YYYY
Will you, as a student of Teen Challenge, be willing to authorize doctors or agencies involved in previous treatments to release your medical records?
Yes
No
TELL US ABOUT YOU
Please give us a chronological , bio sketch about who you are, your childhood, any major issues you have had or are now having. This may include your schooling/education, your relationship with your parents, step parents, siblings, etc. We would like to know anything you would like to tell us about who you are:
What is your main problem as you see it?
Why do you want to be admitted?
What do you hope to get out of this program?
I fully acknowledge that the information provided herein is accurate and true to the best of my knowledge, and that this application has been filled out by me. I understand that falsification of information is grounds for denial of my application or may result in my termination from the program if the falsification is determined after entry.
Yes
No
Todays date
MM
DD
YYYY
