Adult & Teen Challenge Baltimore Men's and Women's Home Application

  • Adult & Teen Challenge Baltimore

    Men's Center and MIRA Home for Women

  • Intake Application

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  • Disqualifying Factors:

    1) Individuals who have records of sex offenses which may present a risk to the community due to the City of Baltimore's regulations and restrictions. 

    2) Individuals with legal restraints which would preclude them from participating in the program and which cannot be sorted out by our Admissions office with the legal authority.

    3) Individuals with medical problems which requires excessive time away from our residential program and/or unable to particpate in our work therapy program. 

    4) Individuals taking mind altering or mood changing drugs.

    You Must Agree to the Following:

    1.Are you willing to give up all legal and illegal drugs and alcohol

    2. Are you willing to give up all narcotic and or psychotropic medications. (Anti-Depressants, Anxiety, ADHD, Bi-Polar, Schizophrenia) *With Doctors Approval*

    3. Are you willing to give up all nicotine products?

    4. Are you willing to give up all contact with friends, girlfriends, fiancés to only focus upon yourself and reconciliation with immediate family only?

    5. Are you willing to not have access to your cell phone or any other electronics while being enrolled?

    6. Are you willing to stay enrolled the minimum one year in order to graduate?

  • Personal Information

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  • Do You Currently Get Food Stamps?*

  • Do You Currently Receive SSI/Disability?*

  • Do You Have Any Potential Family Financial Support That May Be Willing to Invest Into Your Time With Us?*

  • Family History

  • Are You Adopted?*
  • Can You Provide a Marriage Certificate Providing Proof*
  • Do you have any children?*
  • Are You Currently Pregnant (Women Only)

  • Parent's marital status while you were living with them?*
  • Are you parents/guardians still live?*

  • Legal History

  • Are You On Probation*
  • Do You Have Any Warrants or Cases Pending?*
  • Are You a Convicted Sex Offender?*

  • History of the Drug Abuse

  • What Substances Have You Used in The Last 90 Days? (Please check all that apply)*
  • What is Your #1 Substance of Choice? (Please check all that apply)*
  • We're You An IV User?*

  • Psychological History

  • Have You Ever Received Mental/Psychiatric Health Treatment*
  • Has A Family Member or Someone Close To You Ever Attempted or Committed Suicide?*
  • Have You Ever Thought About Committing Suicide?*
  • Are You Currently Thinking About Committing Suicide?*
  • Have You Ever Been Diagnosed With Any of The Conditions? Please Check All That Apply:*

  • Treatment History

  • Have You Been To A Teen Challenge Center Before?*
  • Have You Been To Another Treatment Program Before?*

  • Spiritual History

  • Which of these have your participated in?*

  • Are You Born Again?*

  • Military Service History

  • Have You Ever Served in the US Forces.*
  • If You Served What Discharge Did You Receive:
  • Eligible for VA Medical Benefits:

  • Academic History

  • Can You Read and Write:*
  • Can You Read and Write the English Language:*
  • Are You Currently In An Education Program:*
  • Have You Received Any Trade School Training:*

  • Personal History

  • Are you experiencing any of the following? (Please check all that apply)*
  • Check any of the following that best describe you now? (Please check all that apply)*
  • Your Sexual Lifestyle: (Please Check All That Apply)*

  • Have You Ever Suffered from a Eating Disorder?*
  • Have Your Ever Been Sexually Abused?*
  • Have you been treated for any health conditions in the last year?*
  • Do You Have Health Insurance? (Includes Medicaid)*

  • Disclaimer: Adult & Teen Challenge Baltimore reserves the right to prohibit entrance to individuals taking mind and/or mood- altering medications (e.g., Lithium, Prozac, Haldol, Ritalin, Valium, etc.)

    Please note: All medications used to treat depression, anxiety, pain and sleep disorders or other psychological problems are carefully screened at Adult & Teen Challenge Baltimore. Please consult your doctor before considering entry.

  • Personal Questions:

    Please fill these out with great effort and honesty.
  • If accepted are you committed to completed the the one-year commitment?*

  • AGREEMENTS

  • Signature and Submission

  • By signing this applicaton and submitting it you are agreeing that all the information filled in is true and correct to the best of my ability. I understand that if I we're to put incorrect or false information on this application it could result in denial of the application and or dismissal from the program at a further date. 

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