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Height
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Last grade completed
Do you have a GED?
Yes
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Have you served in any branch of the military?
Yes
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Branch
Type of discharge
What is your sexual preference?
Homosexual
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Have you ever engaged in homosexual activities?
Yes
No
How recently
Living Conditions
With whom
How are you supported?
What is your marital status?
Single
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Common Law
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Spouse' Name
Phone Number
Do you have a boyfriend/girlfriend/fiance?
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Do you have dependents?
Yes
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Have you ever experimented with drugs or alcohol?
Yes
No
Longest Period Clean
When was that?
Have you ever been arrested?
Yes
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How many times
Do you have pending drug charges?
Yes
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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
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Rate your general health
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Do you have --
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Do you have -
Epilepsy
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Limitations
Are you presently receiving medical care?
Yes
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Where
Prescriptions
Have you benn hospitalized within the past 12 months?
Yes
No
If yes
Allergies
Have you ever had psychiatric care?
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If yes
Have you ever attempted suicide?
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If yes
How
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Testimonies of Life-Change
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Real Lives, Real Change...
Reba's Story
14:32
John's Story
14:32
Recovery IS Possible
14:32
Addiction Affects Everyone
0:16
Alfredo's Story
Anthony's Story
Mark's Story
Cynthis's Story
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