FIND YOUR PURPOSE. PROTECT YOUR FUTURE. Women's Application "*" indicates required fields Step 1 of 14 0% PhoneThis field is for validation purposes and should be left unchanged.PERSONAL DATA AND INFORMATIONLast Name*First Name*MI*Address* Street Address City State / Province / Region ZIP / Postal Code Home Phone*Work PhoneGender at birth*Select optionMaleFemaleWeight*Height*Hair color*Eye color*Social Security Number*Birth Date* MM slash DD slash YYYY Age*Do you have a driver's license?*Select optionYesNoDriver's License Number*State*Select optionAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificDriver's License Condition*Select optionValidExpiredSuspendedIf Suspended, explain* Emergency ContactDo you have an emergency contact?*Select optionYesNoFull Name*Relationship*Address* Street Address City State / Province / Region ZIP / Postal Code Home Phone*Work Phone Who has referred you to teen challenge?Did someone refer you?*Select OptionYesNoFull Name*Relationship*Address* Street Address City State / Province / Region ZIP / Postal Code Home Phone*Work Phone Race/Ethnic backgroundYour race/ethnic Please check only one)* American Indian or Alaska Native Asian Black or African American Latino/Hispanic Native Hawaiian or Other Pacific Islander White Other Are you a United States citizen?* Yes Native Naturalized No If no, explain* MARITAL/ INTIMATE RELATIONSHIP HISTORYMarital StatusSingleMarriedCommon LawSeparatedDivorcedWidowedRemarriedDiscribe any concerns related to this relationshipDo you have any children?Select optionYesNoIf yes, please list. Name of child Age Where living Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. Do you have Child Protective Service (CPS) involvement?*Select optionYesNoIf yes, who is case worker?*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone*Sexual lifestyle* Bisexual Heterosexual Homosexual Transsexual Any recent involvement?*Select optionYesNoHave you ever engaged in homosexual activities?*Select optionYesNoExplain* Legal HistoryAre you on probation or parole?*Select optionYesNoMethod of reporting*Select optionPhoneLetterIn PersonIf in person, explain*How often do you report?*Time remaining*Probation or Parole Officer's name*Agency*Phone Number*Are any of the following pending against you? (Please check all that apply)* Arrest Warrant Court Appearance Criminal Charges Sentencing Other If you have checked any of the above, please explain:*Have you ever been arrests or do you have any prior convictions?*Select optionYesNoList all arrests and convictions Date Charges Conviction Sentence Time in jail Drug related? Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. Have you ever been in prison?*Select optionYesNoIf yes, provide info below Date Institution Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. Are you registered as a sexual or predatory offender?*Select OptionYesNoIf yes, what level?*Select Option123Are you required to notify the community?*Select OptionYesNoAre you required to notify the Police Department?*Select OptionYesNoHow often are you required to register?*Select Option3 Months6 Months1 Year Financial StatusAre you eligible for and/or receiving public assistance?*Select optionYesNoWhat kind of assistance?*Select optionWelfareDisability paymentsUnemployment compensationWorkman's CompensationOtherIf other, explain*Have you ever applied for food stamps?*Select optionYesNoWhere?* Psychological HistoryHave you ever received mental health treatment?*Select optionYesNoIf yes, please list Date Name of Clinic Reason for Mental Health Treatment Outcome Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. Have you ever received psychiatric care?*Select optionYesNoIf yes, explain*Will you, as a student of Teen Challenge, be willing to authorize doctos or agencies involved in previous treatments to release your medical records?*Select optionYesNo Insurance InformationSelect your health insurance type*Select optionNo health insuranceMedicaid/MedicareOther private insuranceInsurance policy number*Company* Medical HistoryAre you pregnant or think you might be pregnant?*Select optionYesNoUnknownDo you have any previsions or current medical conditions?*Select optionYesNoDescribe any previous and current medical conditions*Do you currently take medication?*Select optionYesNoList all medications you are currently taking*Do you have any allergies?*Select optionYesNoList your allergies below*Have you ever struggled with: Anorexia Bulimia Self Harm Abusing others Sex Pornography Gambling Over-eating Stealing Video Games Work-a-holic Internet/social media Shopping None of the above If yes to any, explainDo you use nicotine?*Select optionYesNoType of nicotine used (cigarettes, vape, etc.)*List how often you use the following drugs:Alcohol* Never Once Several Times Regularly Daily Benzos (Valium, Xanax, etc.)* Never Once Several Times Regularly Daily Amphetamines (Adderrall, Ritalin, etc.)* Never Once Several Times Regularly Daily Opiate Painkillers (Oxy, Roxy, Hydro, etc.)* Never Once Several Times Regularly Daily Heroin/Fentanyl* Never Once Several Times Regularly Daily Methamphetamine (Ice, Glass, Gravel, etc.)* Never Once Several Times Regularly Daily MDMA (Ecstasy, Molly, etc.)* Never Once Several Times Regularly Daily Marijuana* Never Once Several Times Regularly Daily Hallucinogenic (Mushrooms, LSD, etc.)* Never Once Several Times Regularly Daily Methadone, Suboxone, etc.* Never Once Several Times Regularly Daily Cocaine (Crack)* Never Once Several Times Regularly Daily Cocaine (powder)* Never Once Several Times Regularly Daily Cold Medication (DXM, Triple C, etc.)* Never Once Several Times Regularly Daily PCP (Sherm, Angel Dust, etc.)* Never Once Several Times Regularly Daily Kratom* Never Once Several Times Regularly Daily IV use of any drug (please specify)* Never Once Several Times Regularly Daily Designer drugs (Bath Salts/K2/2C-X/ 7-OH/Spice)* Never Once Several Times Regularly Daily Spiritual HistoryDo you believe in God?*YesNoUncertainAre you born again?*Select optionYesNoDate* MM slash DD slash YYYY Place*Denominational preferences?* The ProblemWhat is your main problem, as you see it?*Have you ever been in a recovery program other then Adult & Teen Challenge before?*Select optionYesNoWas it:*Select optionReligiousNon-religiousHow many programs have you been in?*List programs: Program Name Date Reason for leaving Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. Have you ever been in a Teen Challenge program?*Select optionYesNoWhen?*Where?*Why did you leave the program?*Select optionDismissed by staffLeft on your ownCompleted the programOtherIf other, what was it?*Why do you wish to be admitted?*Why do you wish to join ATCMA?* The undersigned student applicant fully acknowledges that the information provided herein is accurate and true to the best of his or her knowledge, and that the applicant form has been completed and filled out by student applicant in his or her own handwriting. Student applicant further understands that any false or incomplete information may cause and result in disqualification from admittance into the program. Whether a student is just entering into or is in fact in the program.Digital Signature*Date* MM slash DD slash YYYY If the enclosed application form has been completed or filled out by anyone other than the student applicant, please provide the following: Did someone other than the applicant complete this document?*Select optionYesNoName of the person completing and filling our application form*Relationship to applicant*Date* MM slash DD slash YYYY Explain why student applicant was unable to complete or fill our the enclosed application form* Admission Requirements Applicants requiring detoxification must do so prior to entry. Applicants must be in good health, free of any infections at the time of entry. Medical documentation of any disabilities or medical conditions requiring medication is required to accompany application. Upon entry, applicants will be tested for the Human Immunodeficiency Virus (HIV), Tuberculosis, Syphilis, and Hepatitis. Applicants are required to have read and be familiar with the Student Handbook. By my printed name and signature at the bottom of this page, I understand that upon admission into Adult & Teen Challenge Mid-America: I place myself under the authority of the staff of Adult & Teen Challenge Mid-America. I do hereby acknowledge that I understand the rules and guidelines in the Student Handbook of Adult & Teen Challenge Mid-America. I understand that I will receive disciplinary action, up to and including dismissal from the program, for not following the rules and guidelines of the Student Handbook. Digital Signature*Date* MM slash DD slash YYYY
