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)

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

If YES, please list below

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

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
1
2
3
4
5
6
7

Please list all upcoming court dates and attorney information

	Court Date	Jurisdiction/ Locality of Case	Attorney's Name	Phone#	Email
1
2
3
4
5

List drug history

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
Should be Empty:

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Regenesis Student Enrollment Form