Apply New - Regenesis

PERSONAL DATA AND INFORMATION

Name

Date

Detention Facility (if applicable)

Inmate # (if applicable)

Address

City

State/Province

Zip/Postal

Sexual Orientation:

Heterosexual

Gay

Lesbian

Bi-Sexual

Residence Phone Number

Cell Phone Number

Work Phone Number

Birth Date

Age

Do you have a valid driver’s license?

State

DL Number

Expiration Date

NEXT OF KIN/IN CASE OF EMERGENCY

1st Person Name

Relationship

Address

City

State/Province

Zip/Postal

Telephone

Cell Phone

2nd Person Name

Relationship

Address

City

State/Province

Zip/Postal

Telephone

Cell Phone

WHO HAS REFERRED YOU TO REGENESIS?

Name

Relationship

Address

City

State/Province

Zip/Postal

Telephone

Cell Phone

PERSONAL FAMILY HISTORY

Please list parent/parenting figures, spouse, girl/boyfriend, brothers & sisters (do NOT list your children).

Name

Relationship

Age

Residence

Name 2

Relationship

Age

Residence

Name 3

Relationship

Age

Residence

Name 4

Relationship

Age

Residence

PERSONAL & FAMILY MEDICAL HISTORY

Please explain if you answered any of the above with a yes answer. If you have any problems not listed above, please explain.

Do you have any diet requirements?

Yes

If yes, please explain:

Are you presently taking medication or have open prescriptions?

Yes (List Below)

Medication

Dosage

Medication 2

Dosage

Medication 3

Dosage

Medication 4

Dosage

List your present physician’s name.

Phone

Address

City

State/Province

Zip/Postal

MARITAL/INTIMATE RELATIONSHIP HISTORY

Current spouse (full name)

Address

City

State/Province

Zip/Postal

Residence Phone

Cell Phone

Work Phone

Do you have any children?

Yes (Please list below)

Name of child living

Age

Where they are

Name of child living 2

Age

Where they are

Name of child living 3

Age

Where they are

SIGNIFICANT LIFE EVENTS

Describe any of the following that you are experiencing or have recently experienced.

Death:

Sexual abuse/rape:

Physical abuse/neglect:

Other (specify):

WORK AND EDUCATION HISTORY

Describe other training, certificates, and diplomas:

Describe your skill or employment history (what have you done):

PSYCHOLOGICAL HISTORY

Have you ever received mental health treatment?

Yes (Please list below)

Date

Name of Clinic

Reason for Mental Health Treatment

Outcome

Date

Name of Clinic

Reason for Mental Health Treatment

Outcome

Have you ever thought about committing suicide?

Yes

Are you currently thinking about committing suicide?

Yes

Have you ever received psychiatric care?

Yes

Have you ever cut yourself?

Yes

Have you ever had an eating disorder?

Yes

If yes, please explain:

Will you be willing to authorize doctors or agencies involved in previous treatments to release your medical records?

Yes

SPIRITUAL HISTORY

Are you born-again?

Date

Place

Are you a member of any church?

Yes

Denomination

Have you, your parent or grandparents ever been involved in any occult, cultic, new age or any other non-Christian practices?

Yes

If yes, explain:

LEGAL HISTORY

Are you legally mandated to participate in a residential program?

Yes

If yes, by whom?

Parole Board

Court

Other Other

Explain:

If answer is court, please list County of origin:

Are you currently or will you be under legal supervision?

Yes

Method of reporting:

Phone

Letter

In person

Other (explain)Other (explain)

How often do you report?

How long?

Time remaining?

List your probation/parole officer’s name

Agency

Phone number

Address

City

State/Province

Zip/Postal

Are you required to attend any classes?

How much do you owe in fees, costs, and restitution?

Are any of the following pending against you? (Please check those that apply)

If you have checked any of the above, please explain:

List all arrests and major convictions other than traffic violations:

Date

Charges

Conviction?

Yes

Sentence

Time in Jail

Were Alcohol or Drugs Involved?

Alcohol

Drugs

None

Add another Remove

Please list all upcoming court dates below:

Court Date

Locality/Jurisdiction of Case

Attorney Name

Phone

Add another Remove

FINANCIAL STATUS

Are you eligible for and/or receiving the following:

Welfare

Disability payments

Unemployment compensation

Workman’s compensation

Other incomeOther income

Please Explain:

Have you ever applied for food stamps?

Yes

Where?

THE PROBLEM

What is your main problem, as you see it?

Have you ever been in treatment before?

Was it religious or secular (non-religious)?

What are you expecting (believing) God to do in your life through this program?

Drug

If you did not use drug listed leave blank.

Alcohol

Barbiturates

Benzodiazepines

Cocaine/Crack

Glue/Paint

Heroin

Inhalants (Sniffing)

K2/Spice

Marijuana

MDMA (Ecstasy)

Meth

Mushrooms

PCP

Prescription Drugs

Speed

Tobacco

Other

First Time

How old were you or what month/year?

Alcohol First Time

Barbiturates First Time

Benzodiazepines First Time

Cocaine/Crack First Time

Glue/Paint First Time

Heroin First Time

Inhalants (Sniffing) First Time

K2/Spice First Time

Marijuana First Time

MDMA (Ecstasy) First Time

Meth First Time

Mushrooms First Time

PCP First Time

Prescription Drugs First Time

Speed First Time

Tobacco First Time

Other First Time

Last Time

Please list approximate date of last use.

Alcohol Last Time

Barbiturates Last Time

Benzodiazepines Last Time

Cocaine/Crack Last Time

Glue/Paint Last Time

Heroin Last Time

Inhalants (Sniffing) Last Time

K2/Spice Last Time

Marijuana Last Time

MDMA (Ecstasy) Last Time

Meth Last Time

Mushrooms Last Time

PCP Last Time

Prescription Drugs Last Time

Speed Last Time

Tobacco Last Time

Other Last Time

Frequency

How often did you use: monthly, weekly, daily, etc.

Alcohol Frequency

Barbiturates Frequency

Benzodiazepines Frequency

Cocaine/Crack Frequency

Glue/Paint Frequency

Heroin Frequency

Inhalants (Sniffing) Frequency

K2/Spice Frequency

Marijuana Frequency

MDMA (Ecstasy) Frequency

Meth Frequency

Mushrooms Frequency

PCP Frequency

Prescription Drugs Frequency

Speed Frequency

Tobacco Frequency

Other Frequency

Amount Used

How much did you use per day/week/month?

Alcohol Amount Used

Barbiturates Amount Used

Benzodiazepines Amount Used

Cocaine/Crack Amount Used

Glue/Paint Amount Used

Heroin Amount Used

Inhalants (Sniffing) Amount Used

K2/Spice Amount Used

Marijuana Amount Used

MDMA (Ecstasy) Amount Used

Meth Amount Used

Mushrooms Amount Used

PCP Amount Used

Prescription Drugs Amount Used

Speed Amount Used

Tobacco Amount Used

Other Amount Used

Alternate

*If the application form has been completed or filled out by anyone other than the student applicant, please provide the following:

1. Name of the person completing and filling out the application form:

2. Relationship to applicant:

3. Explain why the applicant was unable to complete or fill out the application form:

Signature

Clear

Date