Application for Admission

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Grace House Indiana Teen Challenge

1.	Name:
		First		Middle		Last

2.

Present Address:

Street

City

State

Zip

Phone:

Social Security #:

3.	Referred to Teen Challenge by:
		Name				Phone
	Address			City				State		Zip
	Relationship (Friend, Relative, etc.)

1.

Birthdate:

/     /

Age:

Sex:  M  F

Weight:

Height:

2.

Race:

White  Black  Asian or Pacific Islander Hispanic  American Indian   Other

3.

Are you an American Citizen?

Yes  No

4.	Are you living on your own?		Yes  No
	Reason for leaving home:

5.	What kind of problems did you have while living at home?

6.

Last grade completed:

GED?  Yes  No

7.	Have you served in any branch of the military?  Yes  No		Which Branch?
	Type of discharge:

8.	Do you have any Reserve or military obligation at this time?  Yes  No
	If yes, explain:

9.	What is your sexual preference?  Homosexual  Bisexual  Transsexual  Heterosexual

10.

Have you ever engaged in homosexual activities?    Yes  No

How recently?

11.	What are your present living conditions?		With Whom?		Where?
	How are you supported?

12.	What significant changes have occurred in your life recently?	(Behavior, employment, activities, etc.)

1.	Single  Married  Separated  Divorced  Common Law  Widowed    Remarried

2.	Spouse or Ex-Spouse’s Full Name:				Phone:
	Address			City				State		Zip

3.	If separated or divorced, please give date:
	Reason for breakup:
	What is the relationship like now?

4.	Do you have a boyfriend/girlfriend/finance’?    Yes  No
	If yes, what is the relationship like?

5.	Do you have dependents?    Yes  No

Dependent’s Name	Birthdate	Age	Other Parent’s Name	Child Support	Custody
					Me	Other

1.	Have you ever experimented with drugs or alcohol?    Yes  No

2.	Why did you experiment with or become involved with drugs?

Drugs used:	Usage		How Often Used?
	1st Time	Last Time	Once	Several	Often	Regularly
Alcohol
Barbiturates (downers)
Amphetamines (uppers)
Heroin
Cocaine
Hallucinogenics
Opium
Glue
Tobacco
Marijuana
Other (Specify)

3.	Do you consider yourself addicted?    Yes  No
	Explain:

4.	I depend on drugs (Check which one(s) apply to you)    To cope with life  To be “in” with crowd
	For pleasure  To escape reality  Other

5.

Longest period clean?

When was that?

1.

Have you ever been arrested?    Yes  No

How many times?

Date	Charges	Convicted? (Yes or No)	Sentence	Time Served

2.

Are there pending charges?    Yes  No

If yes, when is court date?

3.

Have you ever been on probation?    Yes  No

Are you now on probation?  Yes  No

How long have you been on probation?

Time remaining?

How do you report?  In person  By Mail

How often do you report?

Name of Probation Officer:

Phone:

Address:

Are you on parole?  Yes  No

How do you report?  In person  By Mail

How often do you report?

Name of Parole Officer:

Phone:

Address:

4.

Have you ever been in prison?    Yes  No

When?

Where?

5.	Name of Lawyer:			Phone:
	Address:

1.	Do you believe in God?    Yes  No  Uncertain
2.	Have you ever committed your life to God?  Yes  No
	If so, Where?					Date:
	a.    What were the circumstances that led to your decision?
	b.    How many times have you turned from God?
3.	How often do you attend church?  Never  Sometimes  Regularly
	Denominational preference:
4.	Are you a member of any church or religion?  Yes  No
	If yes, which one?
5.	What recent changes have you had in your religious life (if any)?
6.	Have you ever been involved in the occult?  Yes  No
7.	Explain your need of God, what your standing with Him is now (ie: good or bad relationship, no relationship at all, etc)

1.	Are you receiving welfare, unemployment compensation, disability payments, workman’s compensation, alimony, or other income?    Yes  No
	Explain:
2.	Do you have any outstanding debts or fines?  Yes  No
	Explain:

Owed to	Amount	Address	Phone	Payments

1.	What is the main problem in your life, as you see it? (Why are you wanting to come here?)

2.	What have you done about it?

3.	What are your greatest needs, in order of priority?

4.	Have you ever been involved in a Teen Challenge program before?  Yes  No  Can’t Remember
	If yes, When?		Where?

5.	Have you ever been in any other type of program before?  Yes  No		How many?
	Religious Non-Religious

Program Name	Dates	City & State	Reason for Leaving

6.	Why do you wish to be admitted to this Teen Challenge program?

7.	What are you expecting (believing) God to do in your life while you are at TC?

8.	Are you expecting God to do it all (“zap” you) or do you believe it will take commitment and sacrifice on your part? Describe what you’re willing to do, or what you think is required of you?

1.	Range your general health:  Excellent  Good  Fair  Poor

2.	Do you have any communicable diseases?  Yes  No	If so, what?
	Do you have epilepsy, seizures, diabetes?  Yes  No	If so, what?

3.	List any medical problems or handicaps:

4.

Are you presently receiving medical care?  Yes  No

If so, where?

5.	Are you currently taking medication?  Yes  No	If so, please list:

6.	Do you have any physical problems due to drugs/alcohol?  Yes  No

7.	Have you been hospitalized within the past 12 months?  Yes  No	If so, please explain:

8.	List all medications to which you are allergic or sensitive:

9.	List all allergies (including food, latex, insects, etc.)

10.	Have you ever had psychiatric care?  Yes  No	If so, please explain:

11.	Have you ever attempted suicide?  Yes  No	If so, How?
	Was it drug or alcohol related?  Yes  No	If so, explain:

12.	What is the condition of your teeth?
	(Must provide a copy of dental exam and must have all necessary dental work completed before coming into Teen Challenge; otherwise must wait until Re-entry and you will be responsible for all expenses incurred. Unless something arises of an emergency nature, you will not be taken to a dentist while in Teen Challenge.)

13	Are you pregnant?  Yes  No  Maybe	Why do you think so?
14	Menopause? (Change of Life)  Yes  No		If so, when?
15	Have you ever had an abortion?  Yes  No		If so, how many times?
	Please explain the circumstances of each time: