Interest Form
Start your new path of life today!
Complete this brief form and an Intake Coordinator will contact you. Hope is within your reach.
Full Name:
*
First Name
Last Name
Age:
*
Phone Number:
*
Address:
*
example@example.com
Emergency Contact Person (Name and Phone Number):
*
Gender at Birth:
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Male
Female
Marital Status:
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Married
Single
Forms of Valid Identification (Check All That Are in Your Possession):
*
State Driver's License
Birth Certificate
Social Security Card
Passport
Marriage License
Military ID
How Did You Hear About Us?
*
Internet Search
Family/Friend
Church
Facebook
Other
Children (Names and Ages); Enter "none" If Do Not Have Children.
*
Any Current, Pending, or Past Charges? Please List Charges or Enter "none."
*
Are You on Probation or Parole?
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Yes
No
List any Upcoming Court Dates or Enter "none":
*
Is the Court Committing You to Teen Challenge? If so, please explain.
*
Health Conditions (Physical/Mental). If No Conditions, Enter "none":
*
Current Prescription Medications?
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Yes
No
Please List Your Medications or Enter "none" If Not Taking Prescriptions.
*
Where Do You Currently Live?
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Your own house/apartment
Staying with someone
Homeless
Have You Been Enrolled in Teen Challenge or a Similar Program Before? If so, list name and location.
*
Please Briefly Describe Why You Are Seeking Help.
*
Submit
Should be Empty: