• 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.
  • 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)
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  • Are you currently taking medication or have open prescriptions? If so please list below
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  • Marital / Relationship History

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  • Significant Life Events

    Describe any of the following that you are experiencing or have experienced
  • Work and Education History

  • Financial Status

  • Psychological History

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  • Spiritual History

  • Legal History

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  • Drug History

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  • Acknowledgement and Signature

  • Should be Empty:
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