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Online Application
Please answer honestly. This information helps us help you. Even with the most sensitive of questions, your absolute candor is required. PLEASE NOTE: Your answers will not be used to disqualify you from our program.
First Name
Last Name
Your E-mail
Telephone
Age
Date of Birth
Address (if homeless, please write "homeless")
Gender
Male
Female
Other
Marital Status
Single
Married
Separated
Divorced
Window(er)
Do You Have Children
Yes
No
Education Level
High School Diploma
G.E.D
B.S / B.A Degree
Master's
Professional / Terminal Degree
Veteran
Yes
No
Branch of Service
Army
Navy
Air Force
Marines
Coast Guard
Religious Background
Catholic
Protestant
Mormon
Jehovah's Witness
Muslim
Jewish
Hindu
Buddhist
Other
Born Again?
Yes
No
Not Sure
I don't know what this means
Previous Substance Abuse Programs, Institutions, Professional Counselors
Have you ever been arrested, charged or convicted of a sex offense
No
Yes
If Yes, Please explain nature of offense
Have you ever been arrested for a felony or misdemeanor (other than sex offense)
No
Yes
If Yes, Please explain nature of offense
Presenting Addictions (check all THAT APPLY)
Marijuana
Cocaine
OxyContin/Vicodin
Fentanyl
Painkillers (Prescription/OTC)
Heroin
Alcohol
Cigarettes
Pornography
Other Not Listed
How long have you been using?
1-3 mo's
3-6 mo's
6 mo -1 year
1-3 years
3-5 years
More than 5 years
Are you currently taking any prescription medications?
No
Yes
If yes, will medication be required while in the program?
No
Yes
Name of Prescribed Medications
Reason for taking
Frequency of use
Prescribed by whom?
How did you hear about Adult & Teen Challenge
Who Referred You?
Self-Referral (myself)
Family
Friend
Counselor
Other
Name of Referral
Expected Program Outcomes
Emergency Contact
Emergency Contact Phone
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