Regenesis Enrollment Form

Regenesis Student Enrollment Form

Regenesis is a minimum 9 month residential personal development program. We have a rigorous working program with 24 hour supervision. The counseling at Regenesis is biblically based and the rules and standards rooted in Christian faith. The use of nicotine products or psychotropic medications are not permitted.
Date
Full Name

First Name Middle Name Last Name
Inmate# (If applicable)
Sexual Orientation

Heterosexual Gay Lesbian Bi-sexual
Birth Date

Month Day Year
Social Security Number
Current Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Email Address
example@example.com
Home #
Cell Phone #
Emergency Contact
Contact #1
Contact #2
Who referred you to Regenesis?
Personal Family History

Please list parents/ parenting figures, spouse, fiancé, boyfriend/girlfriend, brothers and sisters (Do not include children)

Name

Relationship

Age

Residence

Do you have or have ever had any of the following

Asthma Heart Problems HIV Back problems Hepatitis Diabetes Venereal Disease Epilepsy Tuberculosis High Blood Pressure Other
If you checked other, please explain in the field below
Do you have any special dietary requirements and if so please explain
Are you currently taking medication or have open prescriptions? If so please list below

Medication

Dosage

Marital / Relationship History
Marital Status

Married Single Engaged Seperated Divorced Re-married
Spouse /Significant other information
Do you have children?

Yes No

If YES, please list below

Name

Age

Where do the live?

Who do they live with?

Significant Life Events

Describe any of the following that you are experiencing or have experienced
Work and Education History
Can you write?
Can you read?
What is the last year of education completed?
Describe other training, certificates and diplomas
List any skills or employment history (what you have done)
Financial Status
Are you eligible for and /or are receiving any of the following:

Welfare Disability payments Unemployment compensation SSI Workman's compensation Other income
Have you ever applied for food stamps?

Yes No
If YES, where?
Psychological History
Have you ever received mental health treatment?

Yes No

If YES, please list below

Date of treatment

Name of clinic

Reason for Treatment

Outcome

Have you thought about committing suicide?

Yes No
Are you currently thinking about committing suicide?

Yes No
Have you ever cut yourself?

Yes No
Have you ever had an eating disorder?

Yes No
Will you be willing to authorize doctors or agencies involved in previous treatments to release your medical records?

Yes No
Spiritual History
Have you received Christ as Savior?

Yes No
If you have a church home please list name?
Have you, your parents, grandparents or family ever been involved in any occult, cultic, new age or any other non-Christian practices ?

Yes No
If YES, please explain?
Legal History
Are any of the following pending against you?

Arrest warrant Court Appearance Criminal Charges Sentencing Other
If you checked any of the above, please explain?
Are you legally mandated to participate in a residential program?

Yes No
If YES, by whom?

Probation/Parole Court Other
If answer is OTHER, Please explain?
If answer is COURT, list the jurisdiction
Are you currently under supervised probation?

Yes No
If YES complete the following:
How much do you owe in court fees and/or restitution?

List all arrests and major convictions other than traffic violations

Date

Charges

Were you convicted?

What was your sentence

How long were you incarcerated?

Was alcohol (A) or Drugs (D) involved

Please list all upcoming court dates and attorney information

Court Date

Jurisdiction/ Locality of Case

Attorney's Name

Phone#

Drug History

List drug history

Drug

First time used

Last time used

How often you used

Amount used

Alcohol

Barbituates

Benzodiazepines

Cocaine/ Crack

Glue/ Paint

Heroin

Inhalants (Snuffing)

K2/Spice

Marijuana

MDMA (Ecstacy)

Meth Amphedimine

Mushrooms

PCP

Prescription Drugs

Speed

Tobacco

Other

Acknowledgement and Signature
By signing in the box below, I acknowledge that all the information that I have submitted is true and accurate (Please type your name)
If this application was filled out by someone other than the applicant, please provide the following
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Regenesis Student Enrollment Form

Emergency Contact

Contact #1

Contact #2

Who referred you to Regenesis?

Personal Family History

Marital / Relationship History

Significant Life Events

Work and Education History

Financial Status

Psychological History

Spiritual History

Legal History

Drug History

Acknowledgement and Signature