Student Application Form - Confidential

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First Name

Middle Name

Last Name

SSN

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Home Phone

Work Phone

Best Contact Phone

Gender

Male

Female

Date of Birth

MM slash DD slash YYYY

Age

Height

Weight

State of Legal Residency

County

Drivers License

Yes

Expired

Suspended

Drivers License No.

Have you ever had a moving violation or ticket?

Yes

I currently Live with

Spouse

Fiance

Girlfriend/Boyfriend

Parents

Other

(indicate "other" for other family member, lock up facility, or other situation)

Indicate below the way in which you were referred to Adult Teen Challenge?

Parents

Relative

Friend

Pastor

Church

ATC USA

Web Site

Radio

Flyer/Bookmark

Therapist/Counselor

Social Worker/Case Manager

Attorney/Public Defender

Other

Please give contact infromation if referred by an individual.

Name

Please give contact infromation if referred by an individual.

Phone

In Case of Emergency Please Notify

Name

Relationship

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Home Phone

Work Phone

Best Contact Phone

Race/Ethnic Background

White

African American

Native American

Asian

Hispanic

Other

Are you an American citizen?

Yes

Please identify your nationality if other than an American Citizen

Marital Status

Single

Engaged

Married

Separated

Divorced

Remarried

Widowed

Name of spouse

Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

If divorced - Name of former spouse

Reason for Breakup

Do you have any children?

Yes

List

Name

Birthday

Age

Sex

Are you court ordered to pay child support?

Yes

Do you owe child support?

Yes

Are your parents married?

Yes

Do they abuse drugs or alcohol?

Yes

Are you close to your parents?

Yes

Please Explain

Do you have any siblings?

Yes

If yes, please list

Name

Birthday

Age

Sex

Do they use drugs or alcohol? (yes or no)

Have you ever engaged in homosexual activity?

Yes

Military History

Branch of military you've served

Army

Marines

Coast Guard

Air Force

Reserves

Navy

Date of Entry

MM slash DD slash YYYY

Date of Discharge

MM slash DD slash YYYY

Rank

Discharge Received

Honorable

Less than Honorable

Dishonorable

Medical

Are you eligible for V.A. Medical Benefits?

Yes

Legal History

Do you need court approval to enter this program?

Yes

Are you currently or will you be under legal supervision?

Yes

Are you legally mandated to participate in a drug recovery program?

Yes

If yes, by whom?

Court

Parole Board

Other

Method of Reporting

Phone

Letter

In Person

Other

How often do your report?

Time remaining for reporting?

Probation Officer's Name

Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Attorney's Name

Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Are any of the following items pending against you?

Arrest Warrant

Court Appearance

Criminal Charges

Sentencing

Other

Do you have any unpaid court costs or fines?

Yes

Have you ever been convicted of a sexual offense?

Yes

Are you required to register as a sex offender'?

Yes

Have you been in a county jail, correctional institution or state prison?

Yes

If yes, please List

Date

Institution

List any arrests and convictions

Date

Arrest/Charges

Sentence/Time served

Financial Information

Are you receiving

Welfare

Unemployment

Disability

Workman's comp

Food Stamps

Social Security

Do you have an income?

Yes

Amount in Savings

Amount in Checking

In what way can you personally contribute financially to the ministry of Teen Challenge?

One-time payment of

Monthly payments of

Academic History

Ability to Read

Yes

Poor

Average

Above Average

Ability to Write

Yes

Poor

Average

Above Average

Check appropriate box or boxes

Graduated from High School

GED

Attended College

AA degree

BA degree

Vocational Training

Vocational Training Certificate

Occupational History

Check the boxes that indicate your work experience

Auto Mechanics

Auto Body

Carpentry

Child Care

Culinary Skills

Computer/Data Entry

Education

Electrical

Office/Clerical

Farming

General Construction

General Maintenance

Health Care

House Keeping

Landscape

Logging

Painting

Plumbing

Retail

Phone Solicitation

Gardening

Present Employment Status

Unemployed

Employed Part-Time

Employed Full-Time

Do you have or have you ever experienced a physical ailment, injury or handicap that would prevent you from performing manual work related tasks while enrolled in a Adult Teen Challenge Program?

Yes

If yes, please explain

Spiritual Background

Are you a member of a church or religion?

Yes

If so, please indentiy the church, denomination or religion

Religious Preference (Check only one)

Assemblies of God

Baptist

Catholic

Jewish

Pentecostal

Presbyterian

Lutheran

Evangelical Covenant

Methodist

Muslim

Evangelical Free

Other

Personal Walk with God:

I have accepted Jesus Christ as my Savior

Yes

Date

MM slash DD slash YYYY

I have been baptized in Water

Yes

Date

MM slash DD slash YYYY

I have been filled with the Holy Spirit

Yes

Date

MM slash DD slash YYYY

I attend Church

Often

Occasionally

Seldom

Never

I read the Bible

Often

Occasionally

Seldom

Never

I pray

Often

Occasionally

Seldom

Never

Describe God in your own words

Describe how you believe God feels when he sees you

What is your current spiritual condition?

What would you like God to do specifically for you?

Recovery

Reason(s) for seeking entry into Adult Teen Challenge at this time

Want to change by doing things God's way

Want to change my lifestyle

Want to avoid arrest

Pleasing my family

Want to restore my family

Don't want to be controlled by addictions

Want to get public assistance

Want to be self supporting

No other options

Ordered to by the courts

I want to enter Adult Teen Challenge’s 12-15 month program because

I feel the main issues I need to work on are

Once I graduate the program, my goals in life are to:

Full Name

, understand and acknowledge that the information provided herein is accurate and true to the best of my knowledge. I further understand that any false or incomplete information may cause and result in disqualification from admittance or dismissal from the program.

Signature

Applicant's Signature

Date

In the event this application was filled out by another, please identify the reason why the applicant was unable to complete this for themselves and sign below.

Name

Sign Below

Signature

Date

Notice, it is hereby understood that Teen Challenge of Wisconsin will not be held responsible for any personal property left, lost or stolen while in the Teen Challenge of Wisconsin program. I agree that any property or money left at Teen Challenge of Wisconsin over 14 days from my departure date, voluntarily or not, announced or unannounced becomes the property of Teen Challenge of Wisconsin. It is further understood that there is a $995 induction fee which is payable upon entry into the program and is non-refundable. I also understand that if I am dismissed from Teen Challenge of Wisconsin or decide to leave the program I must leave within 24 hours. If I become belligerent, abusive, uncooperative, or threatening I must leave the facility immediately. It is important that medical, dental, business and legal needs be taken care of before entering the Teen Challenge of Wisconsin program. If you have such needs that cannot be taken care of before entering Teen Challenge of Wisconsin please call the center and explain your situation.

Sign Below

Applicant's Signature

Date

Medical History Questionnaire

Applicants Name - First Name

Middle Name

Last Name

Sex

Male

Female

Date of Birth

MM slash DD slash YYYY

Height

Feet

Inches

Applicants Blood Type

Current Physician - Name

Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Teen Challenge International Wisconsin Centers are committed to helping students become physically, mentally and spiritually whole. We are not, however, a medical program. We will endeavor to assist you in securing whatever medical help we can while you are in the program. If you become ill or need medical attention once you are in the program we will assist in connecting you with a medical facility. You are responsible for any fees that accrue in connection with your visit to or treatment from any medical facility. We do not financially assist students in meeting their medical bills.

Health Insurance

Yes

Insurance Company

Policy Number

Will you have insurance while in the program?

Yes

Insurance Company Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Do you collect disability payments?

Yes

Personal Medical History

Do you need any ongoing medical treatment or physical therapy while enrolled in Adult Teen Challenge?

Yes

If yes, please explain

Are you experiencing or have you experienced an injury or illness that affects your ability to participate in: Manual Work Experience

Yes

Exercise Programs

Yes

Recreational Activities

Yes

If yes to any of the above, please explain

Please list any food allergies

Check if you have

Chronic Backaches

Chronic Headaches

Chronic Cough

Chronic Fatigue

High Blood Pressure

Low Blood Pressure

Hemorrhoids

Double Vision

Blurred Vision

Loss of Sight

Loss of Hearing

Ear Infections

Heart Burn

Acid Reflux

Hay Fever

Arthritis

Heart Trouble

Seizures

Epilepsy

Black Stools

Kidney Stone

Diabetes

Dizziness

Blackouts

Convulsions

Ulcers

Jaundice

Syphilis

Asthma

Sinus Trouble

Chlamydia

AIDS

Gonorrhea

Hepatitis

Herpes

Are you Experiencing

Poor Appetite

Frequent Diarrhea

Frequent Urination

Blood in Urine

Depression

Nausea

Frequent Indigestion

Frequent Constipation

Bladder Infections

Coughing up Blood

Vomiting

Severe Itching

Problems Urinating

Problems Sleeping

Panic Attacks

Vomiting Blood

Intestinal Parasites

Persistent Weight Gain

Persistent Weight Loss

Nervous Breakdown

Are you currently taking any medications for any of the conditions mentioned above?

Yes

If so, please identify the medications (by name) that you are taking, dosage and frequency:

Have you had

Whooping Cough

Typhoid Fever

Chicken Pox

Tuberculosis

Scarlet Fever

Pneumonia

Measles

Head Injury

Mumps

Cancer

Small Pox

Anemia

Covid-19

If you have had a head injury where you lost consciousness or were admitted to a hospital for evaluation, please give the date and explain the nature of your injury, any medical treatment you received, and any difficulties that resulted from the injury in the space below. (memory loss, lack of concentration, headaches, vision problems etc.)

List Here

Have you been treated for or Diagnosed with

Schizophrenia

Multiple Personalities

Hearing Voices

Suicide Attempts

Hallucinations

Flashbacks

Nervous Condition

Homicidal Thoughts

ADD

ADHD

PTSD

Anxiety

Paranoia

Insomnia

Depression

Bipolar

Suicidal Thoughts

Are you currently taking any medications for any of the conditions mentioned above?

Yes

If so, please identify the medications (by name) that you are taking, dosage and frequency:

Do you have any special diet restrictions or requirements?

Yes

Please explain

Date of your last dental exam

MM slash DD slash YYYY

Condition of your teeth

Excellent

Good

Fair

Poor

Please describe any problems that you are experiencing with your teeth.

How many packs of cigarettes do you smoke per day?

Do you use chewing tobacco?

Yes

Have you ever received mental health treatment not related to drug or alcohol use?

Yes

Name of Clinic

Date

MM slash DD slash YYYY

Reason for Mental Health Treatment

Name of Clinic

Date

MM slash DD slash YYYY

Reason for Mental Health Treatment

Would you be willing to authorize release of information from the above clinics to Adult Teen Challenge?

Yes

Have you experienced an eating disorder such as anorexia or bulimia?

Yes

Substance Abuse and Treatment History

Have you ever been in a treatment program before?

Yes

How many programs have you been in before Adult Teen Challenge?

List the treatment programs you have been in before the Adult Teen Challenge Program:

Program Name

City / State

Date of Entry

Length of Program

Did you complete?

Why you left if you didn't finish

Have you ever been in the Adult Teen Challenge Program before?

Yes

If yes, when?

Program Name

Location

Untitled

Graduated

Completed program

Dismissed by staff

I left on my own

Other

If dismissed by staff, please explain why

Do you currently have any relatives in our program?

Yes

Please use the chart below to describe your use of alcohol and drugs

When answering the question of "How Often Taken", use O for Once, ST for Several Times, R for Regularly and C for Continuous usage

Alcohol

CURRENTLY USING (Y/N)

PRESCRIBED BY A PHYSICIAN (Y/N)

AGE WHEN FIRST USED

AGE WHEN LAST USED

HOW OFTEN TAKEN

Alcohol Method of Administration

Oral

Smoke

Snort

Amphetamines/speed (Uppers Benzedrine, Dexedrine, etc.)

CURRENTLY USING (Y/N)

PRESCRIBED BY A PHYSICIAN (Y/N)

AGE WHEN FIRST USED

AGE WHEN LAST USED

HOW OFTEN TAKEN

Amphetamines/speed Method of Administration

Oral

Smoke

Snort

Barbituates / Downers

CURRENTLY USING (Y/N)

PRESCRIBED BY A PHYSICIAN (Y/N)

AGE WHEN FIRST USED

AGE WHEN LAST USED

HOW OFTEN TAKEN

Barbituates / Downers Method of Administration

Oral

Smoke

Snort

Chew - Tobacco

CURRENTLY USING (Y/N)

PRESCRIBED BY A PHYSICIAN (Y/N)

AGE WHEN FIRST USED

AGE WHEN LAST USED

HOW OFTEN TAKEN

Chew Tobacco Method of Administration

Oral

Smoke

Snort

Cocaine/crank/crack

CURRENTLY USING (Y/N)

PRESCRIBED BY A PHYSICIAN (Y/N)

AGE WHEN FIRST USED

AGE WHEN LAST USED

HOW OFTEN TAKEN

Cocaine/crank/crack Method of Administration

Oral

Smoke

Snort

Codeine

CURRENTLY USING (Y/N)

PRESCRIBED BY A PHYSICIAN (Y/N)

AGE WHEN FIRST USED

AGE WHEN LAST USED

HOW OFTEN TAKEN

Codeine Method of Administration

Oral

Smoke

Snort

Hallucinogens (LSD, Acid, Mescaline, etc.)

CURRENTLY USING (Y/N)

PRESCRIBED BY A PHYSICIAN (Y/N)

AGE WHEN FIRST USED

AGE WHEN LAST USED

HOW OFTEN TAKEN

Hallucinogens Method of Administration

Oral

Smoke

Snort

Heroin/Opiates

CURRENTLY USING (Y/N)

PRESCRIBED BY A PHYSICIAN (Y/N)

AGE WHEN FIRST USED

AGE WHEN LAST USED

HOW OFTEN TAKEN

Heroin/Opiates Method of Administration

Oral

Smoke

Snort

Inhalants (Glue, Paint, Gasoline, etc.)

CURRENTLY USING (Y/N)

PRESCRIBED BY A PHYSICIAN (Y/N)

AGE WHEN FIRST USED

AGE WHEN LAST USED

HOW OFTEN TAKEN

Inhalants Method of Administration

Oral

Smoke

Snort

Marijuana/K2

CURRENTLY USING (Y/N)

PRESCRIBED BY A PHYSICIAN (Y/N)

AGE WHEN FIRST USED

AGE WHEN LAST USED

HOW OFTEN TAKEN

Marijuana/K2 Method of Administration

Oral

Smoke

Snort

Methadone - non-legal

CURRENTLY USING (Y/N)

PRESCRIBED BY A PHYSICIAN (Y/N)

AGE WHEN FIRST USED

AGE WHEN LAST USED

HOW OFTEN TAKEN

Methadone Method of Administration

Oral

Smoke

Snort

PCP (Angel Dust, etc.)

CURRENTLY USING (Y/N)

PRESCRIBED BY A PHYSICIAN (Y/N)

AGE WHEN FIRST USED

AGE WHEN LAST USED

HOW OFTEN TAKEN

PCP Method of Administration

Oral

Smoke

Snort

Tobacco - smoking

CURRENTLY USING (Y/N)

PRESCRIBED BY A PHYSICIAN (Y/N)

AGE WHEN FIRST USED

AGE WHEN LAST USED

HOW OFTEN TAKEN

Tobacco Method of Administration

Oral

Smoke

Snort

Other (specify)

CURRENTLY USING (Y/N)

PRESCRIBED BY A PHYSICIAN (Y/N)

AGE WHEN FIRST USED

AGE WHEN LAST USED

HOW OFTEN TAKEN

Other (specify) Method of Administration

Oral

Smoke

Snort

Specify if other filled out above.

The undersigned fully acknowledges that the information provided herein is accurate and true to the best of his or her knowledge. Any false or incomplete information may cause and result in disqualification from admittance or dismissal from the program.

Sign Below

Applicant

Date

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

Name of individual filling out the form

Date

Downloads

What to Bring List
Things Potential Students Need to Know
Student Communication Policy
Physical Form for DR.
Family, Friends Sponsorship Sheet
Financial Requirements

I was tired of getting high. I wanted to stop but didn’t know how. I decided to go to the Mental Health Complex because I knew it was a safe place where I could get help. There, a priest told me that Jesus was the only one that could help me. He told me about Teen Challenge. -Phyllis

During this last year the Lord has helped me immensely. I am rebuilding my life in Christ. I graduated last month and will be entering Brooklyn Teen Challenge School of Ministry in October. Thank you for supporting Teen Challenge Wisconsin! Your support helps those struggling with addiction find freedom. -Alex Willis

We can also help you in your search for other residential treatment center for teens, addiction treatment centers, youth alcohol treatment centers, Teen Challenge schools, Christian addiction treatment or military schools. These Midwest alcohol rehab centers will specifically target alcoholism. Adult & Teen Challenge centers are long-term addiction recovery programs that are affordable, solving addictions for men in Wisconsin and Illinois, from the Chicago area, to Milwaukee and Madison, including Cudahy, South Milwaukee, Elm Grove, Butler, Brookfield, Menomonee Falls, Waukesha, Germantown, Pewaukee, Rockford.

Student Application Form