Student manual application for online

Intake Coordinator:
Date: Initials:
Date:

MonthDayYear
Date
Date: Initials:
Comments:
Student Application Form - Confidential

Name SSN:
First
Last
SSN:
Zip
Home Phone: Work Phone: Best Contact Phone:
Home Phone:
Address

Male ❑ Female Date of Birth: / / Age: Height: Weight:Home Phone: Work Phone: Best Contact Phone:
Work Phone:
Best Contact Phone:
Male ❑ Female Date of Birth: / / Age: Height: Weight:
Date of Birth:

MonthDayYear
Date
Age:
Weight:
State of Legal Residency: County:
State of Legal Residency:
County:
Driver’s License: ❑ Yes

NoExpiredSuspended Driver’s License No
Driver's License No.
Have you ever had a moving violation or ticket?

Yes ❑ NoI currently live with:SpouseFianc
Girlfriend/Boyfriend ❑Parents

Other Family Member:Lock up Facility:Other:
Indicate below the way in which you were referred to Life Change Centers?

ParentsRelativeFriendPastorChurchNational TC OfficeWeb SiteRadioFlyer/BookmarkAdvertisementTherapist/CounselorSocial Worker/Case ManagerAttorney/Public Defender ❑ Other:
Attorney/Public Defender ❑ Other:

Please give contact information if referred by an individual

Name Phone
Name
In Case of Emergency Please Notify:

Name Relationship
Relationship
Address
City
Home Phone: Work Phone: Best Contact Phone:
Race/Ethnic Background

WhiteAfrican AmericanNative AmericanAsianHispanic
Other: Are you an American citizen? ❑ Yes ❑ No
Please identify your nationality if other than an American Citizen:
Marital Status:

SingleEngagedMarriedSeparatedDivorcedRemarriedWidowed
Name of Spouse
Phone
State
If divorced Name of former spouse:
Reason for Breakup:
Do you have any children? ❑ Yes ❑ No Name

Are you court ordered to pay child support? ❑ Yes ❑ No Do you owe Child support? ❑ Yes ❑ No Are your parents married? ❑ Yes ❑ No Do they abuse drugs or alcohol? ❑ Yes ❑ No
Yes ❑ No Please Explain:

Are you close to your parents?
Please Explain:
Do you have any siblings? ❑ Yes ❑ No If yes, please list below: Name

Birthday Age Sex Do they abuse drugs or alcohol?
Yes

No
Have you ever engaged in homosexual activity? ❑ Yes ❑ No
Branch of military you've served

ArmyMarinesCoast GuardAir ForceReservesNavy
Date of Entry

MonthDayYear
Date
Date of Discharge_

MonthDayYear
Date
Rank
Discharge Received

Honorableless than HonorableDishonorableMedical
Are you eligible for V.A. Medical Benefits? ❑ Yes ❑ No

Legal History Do you need court approval to enter this program? ❑ Yes ❑ No Are you currently or will you be under legal supervision? ❑ Yes ❑ No Are you legally mandated to participate in a drug recovery program? ❑ Yes ❑ No
If yes, by whom?

CourtParole Board ❑ Other (explain)
In Person ❑ Other (explain)

Method of Reporting ❑ PhoneLetter
How often do you report?
Time remaining for reporting?
Address

Address

Street Address Line 2

CityState / Province

Postal / Zip Code
ST
Zip
Phone
Attorney's Name Phone
Attorney's Address
City ST Zip
Are any of the following items pending against you?

Arrest WarrantCourt Appearance
Are any of the following items pending against you?

Criminal ChargesSentencing ❑ Other (explain)Other (explain)
Do you have any unpaid court costs or fines? ❑ Yes ❑ No Have you ever been convicted of a sexual offense? ❑ Yes ❑ No Are you required to register as a sex offender'? ❑ Yes ❑ No
If yes, please list: Date

Yes ❑ NoHave you been in a county jail, correctional institution or state prison?
List any arrests and convictions. Date
Are you receiving:

WelfareUnemploymentDisabilityWorkman's compFood StampsSocial Security
Do you have an income? ❑ Yes ❑ No Amount in Savings: Checking:
Amount in Savings:
Checking:
In
what way can you personally contribute financially to the ministry of Life Change Centers?

One-time payment of: $ ❑Monthly payments of:
One-time payment of: $ ❑Monthly payments of: $
payments of:
Ability to Read ❑ Yes ❑ No

PoorAverageAbove Average
Ability to Write ❑ Yes ❑ No ❑ Poor ❑ Average ❑ Above Average
Check appropriate box or boxes:

AA degreeBA degreeVocational TrainingVocational Training Certificate
Graduated from High School

Check appropriate box or boxes:GEDAttended College
Other:
Occupational History Check the boxes that indicate your work experience:
Experience:
Other Work

Auto MechanicsAuto BodyCarpentryChild CareCulinary SkillsComputer/Data EntryEducationOffice/ClericalFarmingGeneral ConstructionGeneral MaintenanceHealth CareHouse KeepingLandscapeLoggingPaintingPlumbingRetailPhone SolicitationGardeningOther Work
Present Employment Status:

UnemployedEmployed Part-TimeEmployed 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 Life Change Centers Program? ❑ Yes ❑ No If yes,
If yes,
Spiritual Background Are you a member of a church or religion? ❑ Yes ❑ No

If so, please identify the church, denomination or religion?
religion?
Religious Preference: (Check only one)

Assemblies of GodPentecostalMethodistBaptistPresbyterianMuslimCatholicLutheranEvangelical Free
Religious Preference: (Check only one)

JewishEvangelical Covenant ❑Other:
Evangelical Covenant ❑Other:
Personal Walk with God: I have accepted Jesus Christ as my Savior: ❑ Yes ❑ No Date:

I have been baptized in Water:
No Date:

I have been baptized in Water:Yes
I have been filled with the Holy Spirit: ❑ Yes ❑ No Date:
Date:

MonthDayYear
Date
Often ❑ Occasionally ❑ Seldom

Never
I read the Bible

Often ❑ Occasionally ❑ Seldom ❑ Never
I pray ❑ Often

OccasionallySeldom ❑ 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 Life Change Centers at this time:

Want to change by doing things God's way.Want to change my lifestyleWant to restore my familyWant to be self-supportingWant to avoid arrestDon't want to be controlled by addictionsNo other optionsPleasing my familyWant to get public assistanceOrdered to by the courtsOther:
I want to enter Life Change Centers’ 18 - month program because:
want to enter Life Change Centers' 18 month program because:
I feel the main issues I need to work on are:
feel the main issues I need to work on are:
Once I graduate the program, my goals in life are to:
I, , 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.
Applicant's Signature

Clear
Date

MonthDayYear
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.
Signature

Clear
Notice, it is hereby understood that Life Change Centers of Texas will not be held responsible for any personal property left, lost or stolen while in the Life Change Centers of Texas program. I agree that any property or money left at Life Change Centers of Texas over 14 days from my departure date, voluntarily or not, announced or unannounced becomes the property of Life Change Centers of Texas. I also understand that if I am dismissed from Life Change Centers of Texas or decide to leave the program, I must leave within two 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 Life Change Centers of Texas program. If you have such needs that cannot be taken care of before entering Life Change Centers of Texas please call the center and explain your situation.
Applicant's Signature

Clear
Date

MonthDayYear
Date
Medical History Questionnaire
Applicants Name:
First Last
First
Last
Middle
Male ❑ Female Date of Birth

Sex:
Female Date of Birth

MonthDayYear
Date
Applicants Blood Type
Name
Address
City
Address Life Change Centers International Texas 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 ❑ No Insurance Company:
Yes ❑ No Insurance Company:
Insurance Company:
Policy Number
Will you have insurance while in the program? ❑ Yes ❑ No
Zip
Address

Insurance Co. Address

Street Address Line 2

CityState

Postal / Zip Code
Do you collect disability payments? ❑ Yes ❑ No
No

Do you need any ongoing medical treatment or physical therapy while enrolled in LCC? ❑ Yes
If Yes, please explain:
Recreational Activities ❑ Yes

No
If yes to any of the above, please explain Please list any food allergies Check if you have:

Chronic BackachesDouble Vision ❑ Hay FeverDiabetesAsthmaChronic HeadachesBlurred Vision ❑ ArthritisDizzinessSinus TroubleChronic CoughLoss of Sight ❑ Heart TroubleBlackoutsChlamydiaChronic FatigueLoss of Hearing ❑ SeizuresConvulsions ❑ AIDSAre you experiencing or have you experienced an injury or illness that affects your ability to participate in? Manual Work Experience ❑ Yes ❑No Exercise Programs ❑ Yes ❑NoHigh Blood Pressure ❑ Ear Infections ❑ Epilepsy ❑ UlcersGonorrheaLow Blood Pressure ❑ Heart Burn ❑ Black StoolsJaundiceHepatitisHemorrhoids ❑ Acid RefluxKidney StoneSyphilis
Herpes Are you Experiencing:

Poor AppetiteNauseaVomitingVomiting BloodFrequent DiarrheaFrequent IndigestionSevere ItchingIntestinal ParasitesFrequent UrinationFrequent ConstipationProblems UrinatingPersistent Weight GainBlood in UrineBladder InfectionsProblems SleepingPersistent Weight LossDepressionCoughing up BloodPanic AttacksNervous Breakdown
Are you currently taking any medications for any of the conditions mentioned above? ❑ Yes

No If so, please
identify the medications (by name) that you are taking, dosage and frequency:
the
name)
that
you
are
frequency:
and
Have you had:

Whooping CoughChicken PoxScarlet FeverMeaslesMumpsSmall PoxTyphoid FeverTuberculosisPneumoniaHead InjuryCancerAnemia
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
your any you any the injury in the space below. (memory loss, lack of concentration, headaches, vision problems
Have you been treated for or Diagnosed with:
Suicidal Thoughts

SchizophreniaHallucinationsADDAnxietyDepressionMultiple PersonalitiesFlashbacksADHDParanoiaBipolarHearing VoicesNervous ConditionPTSDInsomniaSuicide AttemptsHomicidal Thoughts
Are you currently taking any medications for any of the conditions mentioned above?

Suicidal ThoughtsYes ❑ No If so, please
identify the medications (by name) that you are taking, dosage and frequency:
dosage
taking,
Do you have any special diet restrictions or requirements? ❑ Yes ❑ No Please explain:
explain:
Date of your last dental exam // Condition of your teeth

ExcellentGoodFairPoor Please
Date of your last dental exam

MonthDayYear
Date
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 ❑ No Have you ever received mental health treatment not related to drug or alcohol use? ❑ Yes ❑ No
Name of Clinic
Date

MonthDayYear
Date
Reason for Mental Health Treatment
Would you be willing to authorize release of information from the above clinics to Life Change Centers? ❑ Yes ❑ No Have you experienced an eating disorder such as anorexia or bulimia? ❑ Yes ❑ No

Substance Abuse and Treatment History Have you ever been in a treatment program before? ❑ Yes ❑ No

How many programs have you been in before Life Change Centers? been in before the Life Change Centers Program:

List the treatment programs you have

Length of Did you Date of Entry Program complete?

Why you left if you didn’t finish

Have you ever been in the Life Change Centers Program before? ❑ Yes ❑ No If yes, when?
yes, when?
Program Name: Location:
Program Name:
Location:
Why did you leave?

other:
I left on my own

Why did you leave?GraduatedCompleted program ❑ Dismissed by staff
If dismissed by staff, please explain why:
Do you currently have any relatives in our program?

YesNo
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.

USED: (include street drugs, alcohol, illegal prescriptions, over the counter & other drugs

CHECK USUAL METHOD OF ADMINISTRATION

Amphetamines/speed (Uppers Benzedrine, Dexedrine, etc

Hallucinogens (LSD, Acid, Mescaline, etc

Inhalants (Glue, Paint, Gasoline, etc

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.
Applicant
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

MonthDayYear
Date
Should be Empty: