Delmarva Teen Challenge Application

  • Delmarva Adult & Teen Challenge

    Women's Center Application

  • Disqualifying Factors:

    1. Individuals who have records of violent or sex offenses, which present a risk to the community. 

    2. Individuals with legal restraints which would prohibit them from participating in the program, beyond which can be sorted out by our admissions office with the legal authority. 

    3. Individuals with medical problems which require excessive time away from our residential program. 

    4. Individuals taking psychotropic medications (mind-altering, mood altering medications, sleep aids, etc.)

  • Personal Information

  • Format: 000-000-0000.
  • Format: 000-000-0000.
  • Mark any of the following words that best describe you now:*

  • Are you unsure which words describe you?
  • Is it easy for you to express your feelings?*

  • Marital/Family History

  • Rows
  • Are your parents still living?*
  • Parent's marital status while you were living with them?
  • Growing up, who did you feel closest to?


  • Are you adopted?

  • Significant Life Events

    Describe any of the following that you are experiencing or have experienced, as it applies

  • Child Information

    **Please note that we can only accept children that are not of school age at this time.
  • Rows
  • Are you currently pregnant?*
  • Have you received prenatal care?
  • Do you have any children?*

  • **If you do have minor children, please fill out the child information pages for EACH child listed.

    **If you do not have children, please continue to the academic history section of the application. 

  • Rows
  • Are you seeking program services for both yourself and your child(ren)? * Please note that Home of Hope provides residential services for women with children who are under school age.*

  • Child 1

  • Gender
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  • Is Child Protective Services involved?*
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  • Child 2

  • Gender
  •  - -
  •  -
  • Is Child Protective Services involved?*
  •  -
  •  -

  • Child 3

  • Gender
  •  - -
  •  -
  • Is Child Protective Services involved?*
  •  -
  •  -

  • Child 4

  • Gender
  •  - -
  •  -
  • Is Child Protective Services involved?*
  •  -
  •  -

  • Academic History

  • Highest level of education you have completed*
  • Are you currently enrolled in a education program?*
  • Are you receiving or have you received vocational training (i.e., trade school)?*
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  • Employment History

  • Present employment status:*
  • Rows
  • How long did you hold your last job?*
  • May we contact your employer if necessary?
  • Format: (000) 000-0000.
  • Do you belong to a union?*
  • Have you ever served in the U.S. Armed Forces?*
  • Discharge received
  • Eligible for VA medical benefits

  • Legal Status

  • Are you legally mandated to participate in a Teen Challenge type program?*
  • Have you ever been in prison?*
  • Is any of the following pending against you?*

  • Are you currently or will you be under legal supervision?*
  • Are you currently on parole or probation?*

  • Spiritual History

  • Are you a born-again Christian?*
  • Are you currently affiliated with any church?*
  • How often do you attend church?*
  • How often did you attend church as a child?*
  •  -
  • Have you ever been involved in Christian Science, Jehovah's Witness, Mormonism, Scientology, New Age, Transcendental Meditation, or Eastern Religions?*

  • Have you ever been involved in a homosexual lifestyle?*
  • Do you believe in God?*
  • Do you pray?*
  • Do you read books of other religions?*

  • Health History

    Psychological, Personal/Family, Dependencies

  • Psychological

  • Are you currently in treatment for mental health reasons?*
  • Have you ever received mental health treatment?*
  • Have you ever attempted suicide?*
  • Have you ever thought about committing suicide?*
  • Are you currently thinking about committing suicide?*
  • Has a family member or someone close to you ever attempted or committed suicide?
  • Are you experiencing any of the following? (Please check all that apply)*
  • Will you, as a student of Delmarva Adult & Teen Challenge, be willing to authorize doctors or agencies involved in previous treatments to release your medical records?

  • Personal/Family Medical History

  • Rows
  • Are any of these medications used to treat depression, anxiety, pain, or sleep disorders?*
  • Do you have any special dietary requirements or allergies?*
  • Are you diabetic?*
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  • Have you had recurring convulsions, epilepsy, or fainting spells at any time in the last 5 years?*
  • Do you have current medical needs that require ongoing treatment from a physician? I.e., physical therapy, follow up appointments, etc.*
  • Do you have any health problems that would limit you from complying with the rules and/or standards of this program?*
  • Are you currently experiencing any dental problems?*
  • Have you been treated for any health conditions in the last year?*
  • Do you currently have to see a doctor on a regular basis?*

  • Dependencies

  • Have you ever struggled with (check all that apply):*

  • Rows

  • Disclaimer: Home of Hope reserves the right to prohibit entrance to individuals taking psychotropic medications (mind and/or mood-altering medications). Please consult with your doctor before safely tapering off of such medications prior to entry into our program.

    Please Note: All students accepted into Home of Hope must have a tuberculosis test administered. RESULTS of that test must be submitted on the day of entry.

  • Miscellaneous

    Financial Status, Reason for Entry
  • Have you ever been accepted to a Teen Challenge before?*
  • Are you physically able to sleep in the top bunk?*

  • Financial Status

  • Do you have any financial obligations that would prevent you from fulfilling your commitment to this program?*
  • Do you have debt, bills or financial obligations that will require arrangements, prior to entering the program?*
  • Are you eligible for and/or receiving the following:*

  • Do you currently receive state supplemental food benefits?*
  • Insurance Status:*

  • Reason For Entry

  • Applicant Agreement

  • Signature and Submission

  • The undersigned student applicant fully acknowledges that the information provided herein is accurate and true to the best of her knowledge, and the application form has been completed and filled out by the student applicant. The student applicant further understands that any false or incomplete information may cause and result in disqualification from admittance or continuation in the program. 

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