Online Application - Adult & Teen Challenge (MidSouth)

Application for Admission

General

First

Middle

Last

Street Address

City

State

Zip Code

Phone

Email

Referrer's Name

Your Birthdate

Age

Gender at Birth

Weight

Height

Last grade completed

Do you have a GED?

Yes No

Have you served in any branch of the military?

Yes No

Branch

Type of discharge

What is your sexual preference?

Homosexual Bisexual Transsexual Heterosexual

Have you ever engaged in homosexual activities?

Yes No

How recently

Living Conditions

With whom

How are you supported?

Spouse' Name

Phone Number

Do you have a boyfriend/girlfriend/fiance?

Yes No

Do you have dependents?

Yes No

Have you ever experimented with drugs or alcohol?

Yes No

Longest Period Clean

When was that?

Have you ever been arrested?

Yes No

How many times

Do you have pending drug charges?

Yes No

Court Date

Are you currently on probation?

Yes No

Are you currently on parole?

Yes No

Probation/Parole Officer

Phone

Name of Lawyer

Phone

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

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

Problem

Have you ever been involved in a Teen Challenge program before?

Yes No

When

Where?

Have you been in another recovery program before?

Yes No

How many

If yes

Religious Non-Religious

Rate your general health

Excellent Good Fair Poor

Do you have --

HIV Hepatitis TB

Do you have -

Epilepsy Seizures Diabetes

Medical Issues

Limitations

Are you presently receiving medical care?

Yes No

Where

Prescriptions

Have you benn hospitalized within the past 12 months?

Yes No

If yes

Allergies

Have you ever had psychiatric care?

Yes No

If yes

Have you ever attempted suicide?

Yes No

If yes

How

Drugs involved

Explain

Teeth

Backup Contact

Backup Contact Phone

Testimonies of Life-Change

Real Lives, Real Change...

14:32

0:16

Application for Admission

General

Need help? Call anytime (423) 756-5558 or email info@tcmidsouth.org

About Us

Our Program

Support ATCM

Testimonies of Life-Change

Real Lives, Real Change...

Other Support Options

Application for Admission

General

About Us

Our Program

Support ATCM

Testimonies of Life-Change

Real Lives, Real Change...

Reba's Story

John's Story

Addiction Affects Everyone

Cynthis's Story

Other Support Options