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
January
February
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Day
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1920
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
1
2
3
4
5
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
1
2
3
4
5
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?
1
2
3
4
5
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
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2
3
4
5
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
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2
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7
Please list all upcoming court dates and attorney information
Court Date
Jurisdiction/ Locality of Case
Attorney's Name
Phone#
Email
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2
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5
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
Submit
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