Student Application Step 1 of 24 4% Name(Required) First Middle Last Birth Date MM slash DD slash YYYY AgeGender at Birth Male Female Race American Indian Asian Afro/American Hispanic Multiracial White Other Social Security Number Citizenship United States Other Marital Status Single Married Divorced Engaged Separated Widowed Spouse's Name Spouse's Address Who is filling out this form?(Required) Self Other Please enter the details of the person filling out the form.Name Relationship to Applicant PhoneEmail Preferred method of contact Phone Email Reason for applying Weight (lbs)Height (ft & in) Phone HomePhone CellEmail(Required) Driver's License # Driver's License State Driver's License Status Valid Suspended Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Primary Emergency Contact Name Primary Emergency Contact Relationship Primary Emergency Contact Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Secondary Emergency Contact Name Secondary Emergency Contact Relationship Secondary Emergency Contact Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Officer 1 Name Officer 1 TypeProbation OfficerParole OfficerCourt Ordered JudgeOfficer 1 County Officer 1 Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Officer 1 to be notified when student leaves program Notify Officer Officer 2 Name Officer 2 TypeProbation OfficerParole OfficerCourt Ordered JudgeOfficer 2 County Officer 2 Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Officer 2 to be notified when student leaves program Notify Officer Grade School Highest Level123456789101112College Highest LevelNone12344+Attend any special classes while in school? Do you have any learning disabilities?YesNoAre you able to read?YesNoAre you able to write?YesNoWhat other training have you had?Trades/Skills: (please list)Current Vocation Trade or Profession What substance have you mainly abused? Are you using it/them now?YesNoHow old were you when you first tried illegal drugs?Alcohol Abuse? Yes No Alcohol Amount(Required) Currently Using Alcohol?(Required) Yes No Marijuana Abuse? Yes No Marijuana Amount(Required) Currently Using Marijuana?(Required) Yes No Currently Using Hallucinogens PCP-LSD? Yes No Hallucinogens PCP-LSD Amount(Required) Hallucinogens PCP-LSD Abuse?(Required) Yes No Cocaine/Crack Abuse? Yes No Cocaine/Crack Amount(Required) Currently Using Cocaine/Crack?(Required) Yes No Barbiturates Abuse? Yes No Barbiturates Amount(Required) Currently Using Barbiturates?(Required) Yes No Heroin Abuse? Yes No Heroin Amount(Required) Currently Using Heroin?(Required) Yes No Methadone Abuse? Yes No Methadone Amount(Required) Currently Using Methadone?(Required) Yes No Suboxone Abuse? Yes No Suboxone Amount(Required) Currently Using Suboxone?(Required) Yes No Methaphetamines Abuse? Yes No Methaphetamines Amount(Required) Currently Using Methaphetamines?(Required) Yes No Inhalents Abuse? Yes No Inhalents Amount(Required) Currently Using Inhalents?(Required) Yes No Tobacco Abuse? Yes No Tobacco Amount(Required) Currently Using Tobacco?(Required) Yes No Oxycotin Abuse? Yes No Oxycotin Amount(Required) Currently Using Oxycotin?(Required) Yes No Prescription Med. Abuse? Yes No Prescription Med. Amount(Required) Currently Using Prescription Med.?(Required) Yes No Other Med. Abuse? Yes No Other Med. Amount(Required) Currently Using Other Med.?(Required) Yes No Explain any patterns of drug/alcohol use AND list all current medications for which you have prescriptions.Longest time of sobriety or drug free period When is the longest time of sobriety? What is the main problem as you see it?What are your greatest needs?What have you done about it? Have you ever been in a program before?YesNoWas it religious or non-religious? How many programs have you been in before? Have you ever been involved in a Teen Challenge program before?YesNoIf so, where? and when? MM slash DD slash YYYY Why did you leave?N/ADismissedCompleted ProgramLeft on ownExplain why you left or were dismissed. Did you relapse?YesNoWhat were the circumstances of your relapse?Why do you wish to be admitted to the program?What are you expecting God to do in your life through the program? Spouse support decision to enter ATC? (if married)YesNoSpouse willing to come for counseling?YesNoSpouse or anyone else in your household also a substance abuser?NoAlcoholDrugsDo you have any Children? (amount)No12345678910+Are you paying/owing for child support?YesNoWho is currently caring for your children and when you enter the program? Childcare Phone #Childcare Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Known Allergies Food Known Allergies Medication Known Allergies Other Choose all that apply to your current and past health history. Asthma Drug Abuse HIV/AIDS Alcohol Abuse Head Trauma/TBI Respiratory Problems Back Problems Heart Condition Seizures Diabetes 1 or 2 Hepatitis STI/STD High Blood Pressure Tuberculosis Do you have any current medical concernsAre you currently being treated by a doctor?YesNoFor what? Name of Primary Doctor Phone of Primary DoctorReason for treatment?Date Range of Treatment Are you being treated with prescribed narcotics?YesNo(Applicants on prescribed narcotics will need to complete the regimen prior to admission or switch to non-narcotic pain medications under the advice of their doctor)If yes, what medication? Are you allergic to any medications?YesNoMedication names of non – Psychiatric medications that you are currently being prescribed.Dosages of non – Psychiatric medications that you are currently being prescribed.Reasons of non – Psychiatric medications that you are currently being prescribed.Do you have any type of disability?YesNoIf yes, what type of disability?(Required) Do you have any chronic conditions?YesNoIf yes, what type of chronic conditions?(Required) Do you have any medical restrictions?YesNoIf yes, what type of medical restrictions?(Required) Do you have any known allergies?YesNoIf yes, what type of known allergies?(Required) Have you ever been treated for mental disorder?YesNoIf yes, when?(Required) MM slash DD slash YYYY Have you ever been treated by a psychiatrist/psychologist?YesNoIf yes, when was the last visit?(Required) MM slash DD slash YYYY Choose all that apply to your current and past mental health history. ADD/ADHD Hallucinations Physical Abuse Anorexia Hearing Voices Rape Anxiety Disorder Homicidal Tendencies/Thoughts Bipolar Disorder Insomnia Schizoaffective Disorder Schizophrenia Bulimia Multiple Personalities Sexual Abuse Depression Paranoia Suicide Attempts Flashbacks Personality Disorder Suicide Thoughts Have you thought about, or attempted suicide?YesNoIf yes, how long ago?(Required) Did you receive treatment?(Required)YesNo Are you currently taking any prescribed Psychiatric medications?YesNoMedication names of Psychiatric medications that you are currently being prescribed.(Required)Dosages of Psychiatric medications that you are currently being prescribed.(Required)Reasons of Psychiatric medications that you are currently being prescribed.(Required) Have you ever been arrested?YesNoIf yes, for what and when?(Required)Have you ever been incarcerated?YesNoIf yes, what types of institutions and the dates.(Required) Are you on probation?YesNoParole?YesNoHave you been probated or committed to Teen Challenge by the Court?YesNoDo you have any legal charges pending?YesNoIf yes, where?(Required) For what?(Required) Do you have any outstanding warrants?YesNoIf yes, where?(Required) For what?(Required) Have you ever been convicted of a violent crime?YesNoIf yes, please list each conviction and date.(Required)Have you ever been convicted of a sex related crime?YesNoIf yes, please describe fully.(Required)Are you currently facing charges for a violent or sex related crime?YesNoIf yes, please list each conviction and date.(Required)Are you required to register as a sexual or predatory offender?YesNo Probation Officer's Name Probation Officer's PhoneProbation Officer's County Probation Officer's Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Attorney's Name Attorney's PhoneAttorney's County Attorney's Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Church, if any, attended Are you attending a church now?YesNoIf yes, which one?(Required) Is your spouse attending a church now?YesNoUncertainWant toIf yes, which one?(Required) Do you believe in God?YesNoHave you received Jesus Christ as your Savior?YesNo Are you presently employed?YesNoIf yes, what is your monthly income?(Required) Do you receive any other income? SSI/Disability, etc?YesNoIf yes, what is the monthly amount?(Required) Do you currently receive any government (including military benefits) assistance?YesNoIf yes, what type government assistance?(Required) If yes, what amount?(Required) If yes, how often?(Required) Do you currently receive food stamps?YesNoIf yes, at what state?(Required) Do you have a Case Worker?YesNoCase Worker’s Name Case Worker’s Number ID Case Worker's Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Case Worker’s County Case Worker's Phone #Case Worker's Fax #Case Worker's Email Do you have medical insurance?YesNo Describe any moves that you are currently or have recently experiencedDescribe any losses (personal or financial) that you are currently or have recently experiencedDescribe any sexual abuse/neglect that you are currently or have recently experiencedDescribe any physical abuse/neglect that you are currently or have recently experiencedDescribe any incarcerations that you are currently or have recently experiencedDescribe any ethnic/cultural influences that you are currently or have recently experiencedDescribe any other significant life events that you are currently or have recently experienced Please write a short statement about why you would like to enter Teen ChallengePhoneThis field is for validation purposes and should be left unchanged.
