Student

Student Information

First name *

Last name *

Preferred Name

Middle name

Mailing Address

Address

City

State/Province

Postal Code

Other Contact Info

Phone

Student Details

Gender at Birth

Ethnicity

Date of Birth*

Height

Weight

SSN

Referral (provide contact information of the person who referred you to Teen Challenge)

Referral Type

Referral Name

Address

City

State/Province

Postal Code

Phone

Emergency Contact

Relation to Student

Name

Address

City

State/Province

Postal Code

Phone

Miscellaneous

What are your hobbies, interests, etc?

Additional Notes

Addiction

Addiction Information (mark all that you have used)

Family

Father

Father's Full Name

Relationship

Address

City

State/Province

Postal Code

Phone

Mother

Mother's Full Name

Relationship

Address

City

State/Province

Postal Code

Phone

Siblings

Siblings' Names

Describe your Relationship(s)

Spouse

Spouse/Ex-spouse Name

Marital Status

Address

City

State/Province

Postal Code

Phone

Children

Dependent/Children's Names

Additinal Notes

Describe your Relationship(s)

Health

General Health

Do you have any communicable diseases?

If yes, provide details

Are you presently receiving medical care?

If yes, provide details

Are you on any prescribed medication?

If yes, provide details

Do you have any restrictions?

Dietary

Physical

Allergic

Other

If yes, provide details

Have you ever considered/attempted suicide?

If yes, when was the most recent date?

Have you ever received mental health treatment?

If yes, provide details

Additional Notes

Military

Have you ever served in any branch of the military?

Servied in which branch

Type of discharge

Additional Notes

Legal

Misdemeanors

Assault/Battery

Criminal Mischief

Disorderly Conduct

Disorderly Intoxication

False Crime Report

Indecent Exposure

Loitering/Prowling

Obstructing Justice

Petty Theft

Stalking

Shoplifting

Soliciting/Prostitution

Trespassing

Other Misdemeanor

Felonies

Aggravated Battery/Assault

Battery on an Officer

Burglary

Child Abuse/Neglect

False Imprisonment/Kinapping

Forgery

Grand Theft

Homicide/Murder

Lewd Conduct/Indecent Exposure

Practicing without License

Probation Violations

Resisting with Violence

Robbery Offense

Sexual Battery

Tampering

Weapon Offenses

Other Felony

If yes, provide details

Currently on probation/parole

Method of reporting

Phone

Letter

In-person

Officer's Name

Address

City

State/Province

Postal Code

Phone

Attorney's Name

Address

City

State/Province

Postal Code

Phone

Anything Pending?

Warrants

Court Appearances

Sentencing

Other

If yes, provide details

Additional Notes

Spiritual

Do you believe in God?

Have you ever committed your life to God?

Are you currently involved in a church or religion?

If yes, which?

Describe your current involvement

Additional Notes

Financial

Financial Information

Are you currently employed?

List your most recent jobs

Are you receiving any of the following?

Welfare

Unemployment

Disability

Worker's Comp.

Alimony

Other

If yes, provide details

Do you have any outstanding debts? Include information regarding childsupport, alimony, court fines, probation fees, or other ongoing financial responsibilities

If yes, provide details

Additional Notes

Problem

Do you have any non-drug related issues?

Abusing Others

Abusing Myself

Gambling

Anorexia

Same-sex attraction

Pornography

Sex

Stealing

Video games

Workaholic

Bulimia

Over-eating

What is the main problem in your life, as you see it?

What are your greatest needs, in order of priority?

Why do you want to be admitted?

What do you hope to gain from this program?

How many other programs have you been in?

If yes, provide details

Education

Highest grade level completed

Explain your educational and/or vocational training goals

Additional Notes

Student

Student Information

Mailing Address

Other Contact Info

Student Details

Referral (provide contact information of the person who referred you to Teen Challenge)

Emergency Contact

Miscellaneous

Addiction

Addiction Information (mark all that you have used)

{drug}

Family

Father

Mother

Siblings

Spouse

Children

Health

Health

Do you have any restrictions?

Military

Legal

Legal

Misdemeanors

Felonies

Method of reporting

Anything Pending?

Spiritual

Spiritual

Financial

Financial Information

Are you receiving any of the following?

Problem

Problem

Do you have any non-drug related issues?

Education

Education