Teen Challenge Peoria
Resident Application Form
Date: _______________________ Time: __________________ Staff Name: ______________________
How did you hear about the Teen Challenge Peoria program? _______________________________
Personal Information
Name: ________________________________________ Age: __________ DOB: __________________
Address: _____________________________________________________________________________
City: ____________________________________ State: _________________ Zip Code: ____________
Phone #: _________________________________ Cell #: ______________________________________
SS#: _________-______-_________
Best Way to Contact You: ______________________________
Do you consider yourself a Christian? (Y/N)
What church do you regularly attend? ________________________ City: _________________________
Pastor’s Name: _______________________________________
Sex Offender
>>>Have you ever been convicted of a sex crime or a crime being sexual in nature or threat? (Y/N)
Explain: _____________________________________________________________________________
Marital Status (circle one)
Single
Married
How Long? _______ Separated
Divorced
Widowed
Do you have any children? (Y/N)
How many? _______ Who has custody? ___________________
Ages & Names of your children? __________________________________________________________
Are your currently paying child support? (Y/N) Do you owe child support? (Y/N)
Do you have someone who can transport your children for visitation times? (Y/N) Name:_____________
Relation:___________
General Background (circle one)
High School: Diploma or GED or Grade Level: ____
College (Y/N) Major: _____________________
Military Experience (Y/N) branch ______
Ethnic Background: ______________________
Government Aid (Y/N) SSD or Medicaid or Link or SSI
Current Debt: Medical or Credit or Legal
Ever involved in any homosexual activity? (Y/N)
Gang Involvement? (Y/N) Which one? _________
Tobacco Use (Y/N) Smoke or Chew How Long? ________ How much? _________ Willing to Quit? (Y/N)
Substance Abuse (What Kind, How Much, How Often, Length of Use)
Drugs? (Y/N)Explain:__________________________________________________________________
_____________________________________________________________________________________
Alcohol? (Y/N)Explain:_________________________________________________________________
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NOTES: (office use only)
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Legal Issues
Ever Incarcerated? (Y/N) County or State or Federal Most recent facility, charges & dates?_______________
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Parole? (Y/N) Starting Date: _________________________ Ending Date: _________________________
Parole Officer’s Name: _____________________________ City/County:_________________________
Address:_________________________________________ Phone #:___________________________
Email:_______________________________________________________________________________
Probation (Y/N) Starting Date: ____________________ Ending Date:____________________________
Probation Officer’s Name: _______________________ County: ________________________________
Address: _____________________________________ Phone #:________________________________
Email:_______________________________________________________________________________
Do you have any warrants? (Y/N) Where?___________________________________________________
Are your facing any current criminal charges or court dates? (Y/N) When?_________________________
What are the charges?___________________________ Where?_________________________________
_____________________________________________________________________________________
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Attorney or PD Name: ___________________________ Phone#:________________________________
Do you have any other current legal issues? (Y/N) ____________________________________________
_____________________________________________________________________________________
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Medical Issues
>>>Are you currently on any psychotropic or mood-stabilizing medication? (Y/N)
What (Name, Dosage, Frequency)? ______________________________________________________________
Prescribed by:____________________ Facility:__________________ Phone #:___________________
(circle one)
Do you have a medical diagnosis of suicidal tendency, anger, depression, anxiety,
schizophrenia, bi-polar, or personality disorder? Who diagnosed you? (doctor’s name)_________________
Have your ever received professional help for addiction before? (Y/N)
Where & When?
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Have you ever been in a program, facility, or institution for mental health related issues? (Y/N)
Why, Where & When?
_____________________________________________________________________________________
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Do you have a health condition that requires continual medical treatment? (Y/N) What? ______________
_____________________________________________________________________________________
Are your currently taking any medications? (Y/N) What? ______________________________________
____________________________________________________________________________________
Who prescribed these meds? Name: ____________________________ Phone #:___________________
Do you have any allergies (sinuses or medications or food)? (Y/N) What?__________________________
_____________________________________________________________________________________
Wear Glasses(Y/N) Dental Problems(Y/N) Back Problems(Y/N) Eating Disorder(Y/N) Migraines(Y/N)
Do you think I need to know anything else that might affect your treatment at Teen Challenge Peoria?
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*There is an $970 intake fee. Can you pay for it? Yes/No
Will you need Financial Assistance? Yes/No
>>>Do you have any questions? >>> Can I pray with you?>>>When would you like to come in?>>>
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