Online Application – Adult & Teen Challenge MidSouth

GENERAL

Name *

First

Middle

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Social Security Number *

Phone *

Email *

Email

Confirm Email

How did you learn about us? *

Social media, website, friend, etc.

Referred to Adult & Teen Challenge MidSouth by:

Please give us their name, phone and address (Relationship - Friend, Relative, etc)

PERSONAL

Birthdate *//

Age *

Gender At Birth *

Weight

Height

Race *

Are You An American Citizen? *

Yes
No

Last Grade Completed?

GED?

Yes
No

Have You Served In Any Branch Of The Military?

Yes
No

Which Branch?

Type Of Discharge:

Do You Have Any Reserve Or Military Obligation At This Time?

Yes
No

If Yes, Please Explain:

What Is Your Sexual Preference? *

Homosexual
Bisexual
Transsexual
Straight

Have You Ever Engaged In Homosexual Activities?

Yes
No

How Recently?

What Are Your Present Living Conditions?

With Whom? Where?

How Are You Supported?

MARITAL STATUS

Multiple Choice *

Spouse or Ex-Spouse's Full Name *

First

Middle

Last

Spouse or Ex-Spouse's Phone

Spouse or Ex-Spouse's Address

Address Line 1

Address Line 2

City

State

Zip Code

Do You Have A Boyfriend/Girlfriend/Fiance'? *

Yes
No

Do You Have Dependents? *

Yes
No

Dependent's Name / Birthdate / Age / Other Parent's Name / Child Support

DRUG HISTORY

Have You Ever Experimented With Drugs Or Alcohol? *

Yes
No

Longest Period Clean?

When Was That?

LEGAL HISTORY

Have You Ever Been Arrested? *

Yes
No

How Many Times?

Are There Pending Charges? *

Yes
No

If Yes, When Is Court Date?

What Are The Charges?

Are You Currently On Probation? *

Yes
No

Are You Currently On Parole? *

Yes
No

Time Remaining?

How Do You Report?

In Person
By Mail

How Often Do You Report?

Probation/Parole Officer (NOTE: If none, please type NONE) *

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Email

Confirm Email

Name Of Lawyer *

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Email

Confirm Email

SPIRITUAL STATUS

Do You Believe In God? *

Yes
No
Uncertain

Have You Ever Committed Your Life To God? *

Yes
No

Have You Ever Been Involved In The Occult? *

Yes
No

Denominational Background?

FINANCIAL STATUS

Are You Receiving Welfare, Unemployment Compensation, Disability Payments, Workman's Compensation, Alimony, Or Other Income? *

Yes
No

Explain:

Do You Have Any Outstanding Debt, Fines Or Child Support Obligations? *

Yes
No

Explain:

THE PRESENTING PROBLEM

What Is The Main Problem In Your Life, As You See It? *

Have You Ever Been Involved In An Adult & Teen Challenge Program Before? *

Yes
No
Can't Remember

If Yes, When & Where?

Have You Ever Been In Any Other Type Of Program Before?

Yes
No

How Many?

Faith Based Program?

Yes
No

HEALTH STATUS

Range Your General Health *

Do You Have HIV, Hepatitis or TB? *

Yes
No

If So, What?

Do You Have Epilepsy, Seizures, Diabetes? *

Yes
No

If So, What?

List Any Medical Problems Or Handicaps:

Are There Any Medical Limitations Or Problems That Would Keep You From Being Able To Participate In All Program Activities, Etc. (e.g. Attend Classes, Walk, Climb In A Van, Lawn Care, House Cleaning)

Are You Presently Receiving Medical Care? *

Yes
No

If So, Where?

Are You Currently Taking Prescription Medication? *

Yes
No

If So, Please List:

Have You Been Hospitalized Within The Past Year? *

Yes
No

If So, Please Explain:

List All Medications To Which You Are Allergic Or Sensitive:

List All Allergies (Including Food, Latex, Insects, Etc.):

Have You Ever Had Psychiatric Care? *

Yes
No

If So, Please Explain:

Have You Ever Attempted Suicide? *

Yes
No

If So, How? When?

Was The Suicide Attempt Drug Or Alcohol Related?

Yes
No

What Is The Condition Of Your Teeth?

(You MUST Have All The Necessary Dental Work Completed BEFORE Coming Into Adult & Teen Challenge MidSouth. Unless Something Arises Of An Emergency Nature, You Will Not Be Taken To A Dentist While In Adult & Teen Challenge Midsouth)

Adult & Teen Challenge MidSouth Dental/Medical/Drug Withdrawal Policy

Due to the fact that Adult & Teen Challenge MidSouth is NOT a medical facility, the following policies have been enacted:

DENTAL:

It is STRONGLY ADVISED that residents get a dental check-up prior to entering the program! Residents enrolled in our program WILL NOT have access to a dentist for at least 4 months except for emergencies. In the event of an emergency, the resident’s family will be responsible for any medical costs. If a resident in the program requires on-going dental treatment, they will be required to take a leave of absence. Once the work is completed and we receive verification, they can return to the program.

Date Of Last Dental Check-Up? *

DENTAL - Applicant Signature *

MEDICAL:

Residents will only have access to medical care in case of emergencies. Residents that have a pre-existing condition or a condition that develops while enrolled in the program which requires on-going medical treatment will be required to take a leave of absence. We must receive medical release/ verification before they can return to the program.

MEDICAL - Applicant Signature *

DRUG/ALCOHOL WITHDRAWAL:

Due to the fact that some withdrawal symptoms are unpleasant but some can be FATAL, severe alcoholics and those taking certain medications may require a physician’s statement that you have gone through a detox process or that you have been weaned off the medication under their supervision. If you enter the program but are not able to participate due to drug or alcohol withdrawal for more than 1-2 days, you will be required to take a leave of absence and go through a medically supervised detox. To return to the program, you would need to provide medical verification that you have done so.

DRUG/ALCOHOL WITHDRAWAL - Applicant Signature *

I Have Read And Understood The Above Policies

I Have Read And Understood The Above Policies - Applicant Signature *

RELEASE OF INFORMATION

VERY IMPORTANT: This release of Information document informs Adult & Teen Challenge MidSouth of any person that you want informed of your intent to enter the program, or who may be involved in your intake process. The information exchanged with these people may be utilized to determine your eligibility for the program. This release shall also extend to the development and revision of my treatment plan while enrolled in the program as well as making the transition back to normal life after the program. Because of Federal confidentiality laws, you must list, EVERY person, even immediate family members, that are to be informed of your intent or may be involved in the intake process. In short, if a person’s name is not on the list, we will not be allowed to communicate with them or even acknowledge the receipt of an application, regardless of who they are or their relationship to you. The ONLY exception to this will be in accordance with Federal guidelines.

Name of Probation Officer, Phone/Fax Number

Name of Attorney, Phone/Fax Number

Emergency Contact Name & Address / Title, Relationship, Phone/Fax Number *

Applicant Name *

RELEASE OF INFORMATION - Applicant Signature *

*This consent is subject to revocation in writing by the resident at any time except to the extent that the ministry or person who is to make the disclosure has already acted on it. This consent automatically expires one year and six months from the date it is signed.

AFTER SUBMITTING THIS FORM, PLEASE READ AND CLICK ON THE CONFIRMATION POP UP WINDOW FOR REQUIRED READING DOCUMENTS.