Resident Application Form

Teen Challenge Peoria

Resident Application Form

Date: ______Time: ______Staff Name: ______

How did you hear about the Teen Challenge Peoria program? ______

Personal Information

Name: ______Age: ______DOB: ______

Address: ______

City: ______State: ______Zip Code: ______

Phone #: ______Cell #: ______

SS#: ______-______-______Best Way to Contact You: ______

Do you consider yourself a Christian? (Y/N)

What church do you regularly attend? ______City: ______

Pastor’s Name: ______

Sex Offender

Have you ever been convicted of a sex crime or a crime being sexual in nature or threat? (Y/N)

Explain: ______

Marital Status (circle one)

Single Married How Long? ______Separated Divorced Widowed

Do you have any children? (Y/N) How many? ______Who has custody? ______

Ages & Names of your children? ______

Are your currently paying child support? (Y/N) Do you owe child support? (Y/N)

Do you have someone who can transport your children for visitation times? (Y/N) Name:______

Relation:______

General Background (circle one)

High School: Diploma or GED or Grade Level: ____ College (Y/N) Major: ______

Military Experience (Y/N) branch ______Ethnic Background: ______

Government Aid (Y/N) SSD or Medicaid or Link or SSI Current Debt: Medical or Credit or Legal

Ever involved in any homosexual activity? (Y/N) Gang Involvement? (Y/N) Which one? ______

Tobacco Use (Y/N) Smoke or Chew How Long? ______How much? ______Willing to Quit? (Y/N)

Substance Abuse (What Kind, How Much, How Often, Length of Use)

Drugs? (Y/N)Explain:______

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Alcohol? (Y/N)Explain:______

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NOTES: (office use only)

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Legal Issues

Ever Incarcerated? (Y/N) County or State or Federal Most recent facility, charges & dates?______

______

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Parole? (Y/N) Starting Date: ______Ending Date: ______

Parole Officer’s Name: ______City/County:______

Address:______Phone #:______

Email:______

Probation (Y/N) Starting Date: ______Ending Date:______

Probation Officer’s Name: ______County: ______

Address: ______Phone #:______

Email:______

Do you have any warrants? (Y/N) Where?______

Are your facing any current criminal charges or court dates? (Y/N) When?______

What are the charges?______Where?______

______

Attorney or PD Name: ______Phone#:______

Do you have any other current legal issues? (Y/N) ______

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Medical Issues
Are you currently on any psychotropic or mood-stabilizing medication? (Y/N)

What (Name, Dosage, Frequency)? ______

Prescribed by:______Facility:______Phone #:______

(circle one) Do you have a medical diagnosis of suicidal tendency, anger, depression, anxiety, schizophrenia, bi-polar, or personality disorder? Who diagnosed you? (doctor’s name)______

Have your ever received professional help for addiction before? (Y/N)

Where & When? ______

Have you ever been in a program, facility, or institution for mental health related issues? (Y/N)

Why, Where & When? ______

Do you have a health condition that requires continual medical treatment? (Y/N) What? ______

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Are your currently taking any medications? (Y/N) What? ______

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Who prescribed these meds? Name: ______Phone #:______

Do you have any allergies (sinuses or medications or food)? (Y/N) What?______

______Wear Glasses(Y/N) Dental Problems(Y/N) Back Problems(Y/N) Eating Disorder(Y/N) Migraines(Y/N)

Do you think I need to know anything else that might affect your treatment at Teen Challenge Peoria? ______

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*There is an $970 intake fee. Can you pay for it? Yes/No

Will you need Financial Assistance? Yes/No

Do you have any questions? > Can I pray with you?When would you like to come in?>

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