BREAK’N THE CHAINZ Of ADDICTIONS MINISTRIES, INC.
Confidential
Student Application
Student’s Name____________________________________ SSN: __ __ __ __ __ __ __ __ __
Street: _______________________________________ City : ________________________
State: _______ Zip: _______ Phone: (
) __________________________________
Sex: _______ Date of Birth: _______/_______/_______ Height:____ Weight:____ Age:______
State of Legal Residency:____________ County:________________ Driver License: Y___ N___
Driver License Number:________________________________ Issuing State_______________
Race: White___ Black___ Hispanic___ American Indian ___ Asian ___ Other ___ ____________
Marital Status: Single ___ Married ___ Divorced ___ Separated ___ Widowed ___
I currently live with: Spouse ___ Fiancé/Girlfriend ___ Parents ___ Other Family member ____
Lock up facility: _____________________________ Other: ___
__________________________
Education: (Highest level completed) College Degree ___ Some College ___ Trade School ___
High School ___ GED ___ Other: _______________
I am able to: Read English ___ Write English ___ Speak English ___ Comprehend English ___
Citizenship: United States ____ Other: _______________ Permanent Residency ___ Visa ___
I now have, or have previously had problems with the following: ( Check all that apply)
Gambling ___ Alcohol Addiction ___ Stealing ___ Drug Addiction ___ Lying ___ Violence ___
Pornography ___ Running Away ___ Other: ________________________________________
Military Service: Branch ______________ Yrs of Service ___ Date of Discharge ___/___/___
Emergency Contact: _________________________________ Relationship: _______________
Address: _____________________________ City: ______________ State: _____ Zip: ________
Home Phone: (
) ______ - ____________ Cell Phone: (
)_______ - _____________
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BREAK’N THE CHAINZ Of ADDICTIONS MINISTRIES, INC.
Confidential
Medical Information:
Medical History (Check all that apply to your current or past condition)
Head Trauma ___ Nervous Condition ___ Depression ___ Mental Illness ___ Insomnia ___
Suicide Attempts ___ Suicidal Thoughts ___ Homicidal Thoughts ___ Homicidal Tendencies ___
Paranoia ___ Schizophrenia ___ Multiple Personalities ___ Bulimia ___ Rape ___ Diabetes ___
Hallucinations ___ Physical Abuse ___ Drug Abuse ___ Bipolar Disorder ___ ADD ___ ADHD ___
Venereal Disease ___ Anorexia ___ Disability (describe):________________________________
______________________________________________________________________________
______________________________________________________________________________
Insomnia ____ Tuberculosis ___ Hepatitis (Type:____) HIV/AIDS ____ Seizures ___ Asthma ___
High Blood Pressure ___ Respiratory Problems ___ Heart Condition ___ Back Problems ___
Eating Disorder___
List all current medications you take: 1.__________________ 2. ________________________
3. __________________ 4. __________________ 5. ________________ 6. ________________
List all medications taken in the past 5 years: 1.__________________ 2. __________________
3. __________________ 4. __________________ 5. ________________ 6. ________________
List all Past and Present Dental Problems: 1.__________________ 2. ____________________
3. __________________ 4. __________________ 5. ________________ 6. ________________
Emotional Treatment:
Have you ever been treated by a psychologist? Yes ___ No ___
Have you ever been treated by a psychiatrist? Yes ___ No ___
Have you ever been treated for chemical dependency Yes ___ No ___
Have you ever been treated for sleep disorders? Yes ___ No ___
Have you ever been treated for an eating disorder? Yes ___ No ___
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BREAK’N THE CHAINZ Of ADDICTIONS MINISTRIES, INC.
Confidential
Medical Information (Continued)
Substance Abuse: (Check all that you have used even once)
Heroine ___ Cocaine ___ Crack ___ Crank ___ LSD ___ Methadone ___
Amphetamines (Uppers) ___ Barbiturates (Downers) ___ Marijuana (THC) ___
Alcohol ___ Chewing Tobacco ___ Cigarettes ___ Huffing / Sniffing ___
Mushrooms ___ Hallucinogens ___ Other: ____________________________________
Other: _________________________________________________________________
Prior Treatment Facilities:
(Provide information on all treatment facilities you have been in during the past 5 years.)
Facility Name: _____________________
City: ___________________ State: ____
Phone: (
) ______________________
Dates: _____________ to ____________
(Month /Yr)
(Month /Yr)
Facility Name: _____________________
City: ___________________ State: ____
Phone: (
) ______________________
Dates: _____________ to ____________
(Month /Yr)
(Month /Yr)
Completed Program? Yes ____ No ____
Completed Program? Yes ____ No ____
Facility Name: _____________________
City: ___________________ State: ____
Phone: (
) ______________________
Dates: _____________ to ____________
Facility Name: _____________________
City: ___________________ State: ____
Phone: (
) ______________________
Dates: _____________ to ____________
(Month /Yr)
(Month /Yr)
Completed Program? Yes ____ No ____
(Month /Yr)
(Month /Yr)
Completed Program? Yes ____ No ____
Special Physical Needs: (Check all that apply)
I have a disability: Yes ___ No ___ Type: _____________________________________
I need a special diet: Yes ___No ___ Type: _____________________________________
I have medical restrictions: Yes ____ No ____ Type: _____________________________
Other special needs: ______________________________________________________
Doctor Information:
Name: __________________________________ City ____________________________
State: _____ Phone: (
) ________________ Fax: (
) _______________________
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BREAK’N THE CHAINZ Of ADDICTIONS MINISTRIES, INC.
Confidential
Medical Information (Continued)
General Health:
Excellent: ____ Good ____ Average ____ Poor ____ Very Poor ____
Do you currently have health Insurance: Yes ____ No ____
If yes:
Name of Company: _________________________________________________
Policy # ____________________ Group # _______________________
Phone: (
) ___________________________
Will you have insurance while in the program? Yes ____ No ____
If yes: Name of Company: _________________________________________________
Policy # ____________________ Group # _______________________
Phone: (
) ___________________________
Current Probation/Parole Officer or Caseworker:
Name: ________________________________________________________________________
Street: ________________________________________________________________________
City: _____________________ State: ________Zip: _______
Phone: (
) ____________________ Fax: (
) ____________________________________
Attorney:
Name: ________________________________________________________________________
Street: ________________________________________________________________________
City: _____________________ State: ________Zip: _______
Phone: (
) ____________________ Fax: (
) ____________________________________
Family Information
Do you have any relatives already in our program? Yes_____ No _____
If yes who: _________________________________________ Relation: _____________
Biological Mother’s Name:
Name: _______________________________________________________________________
Street: ________________________________________________________________________
City: _____________________ State: ________Zip: _______ Cell: ( ) ____________________
Phone: (
) ____________________ Fax: (
) ____________________________________
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BREAK’N THE CHAINZ Of ADDICTIONS MINISTRIES, INC.
Confidential
Family Information (Continued)
Biological Father’s Name:
Name: _______________________________________________________________________
Street: ________________________________________________________________________
City: _____________________ State: ________Zip: _______ Cell: ( ) ____________________
Phone: (
) ____________________ Fax: (
) ____________________________________
Spouse’s Name:
Name: _______________________________________________________________________
Street: ________________________________________________________________________
City: _____________________ State: ________Zip: _______ Cell: ( ) ____________________
Phone: (
) ____________________ Fax: (
) ____________________________________
Work: (
) ____________________
If Divorced:
Name: _______________________________________________________________________
Street: ________________________________________________________________________
City: _____________________ State: ________Zip: _______ Cell: ( ) ____________________
Phone: (
) ____________________ Fax: (
) ____________________________________
Work: (
) ____________________
Reason for break-up: ___________________________________________________________
_____________________________________________________________________________
I have the following children:
Name: ___________________________ D.O.B. ______________ Age: ____ Sex: ____
Name: ___________________________ D.O.B. ______________ Age: ____ Sex: ____
Name: ___________________________ D.O.B. ______________ Age: ____ Sex: ____
Name: ___________________________ D.O.B. ______________ Age: ____ Sex: ____
I have the following siblings:
Name: ___________________________ D.O.B. ______________ Age: ____ Sex: ____
Name: ___________________________ D.O.B. ______________ Age: ____ Sex: ____
Name: ___________________________ D.O.B. ______________ Age: ____ Sex: ____
Name: ___________________________ D.O.B. ______________ Age: ____ Sex: ____
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BREAK’N THE CHAINZ Of ADDICTIONS MINISTRIES, INC.
Confidential
Spiritual Information
Religious Preference: (Check only one)
Assemblies of God ____ Pentecostal ____ Methodist ____ Baptist ____ Presbyterian ____
Muslim ____ Catholic ____ Lutheran ____ Evangelical Free ____ Jewish ____
Evangelical Covenant ____ Non Denominational ____ Other ____ ___________________
Personal walk with God:
I have accepted Jesus Christ as my Savior: Yes: ____ No ____ Date: _____/______ /______
I have been baptized in water: Yes: ____ No ____ Date: _____/______ /______
I have been filled with the Holy Spirit: Yes: ____ No ____ Date: _____/______ /______
I attend church
______ Often ______ Occasionally____ Seldom ____ Never
I read the Bible
______ Often ______ Occasionally____ Seldom ____ Never
I pray
______ Often ______ Occasionally____ Seldom ____ Never
Church Affiliation:
Church Name: _____________________________________________________________
How long have you attended this church? ______ Pastor: __________________________
Street: ________________________ City: _______________ State: ______ Zip: __________
Phone: (
) ____________________ Fax: (
) ____________________________________
Other Spiritual Practices:
____Satan worship
____Ouija board
____Psychics
____Black magic
____Witchcraft
____Séances
____Fortune tellers
____Animal sacrifices
____Occults
____Palm reading
____Voodoo
____Astrology
Describe God in your own words:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Applicant Statement
Have you ever been convicted of :
Arson __ Y __N Sex Offenses ___Y ___N
Explain in detail if yes
______________________________________________________________________________
______________________________________________________________________________
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BREAK’N THE CHAINZ Of ADDICTIONS MINISTRIES, INC.
Confidential
Describe how you believe God feels when he sees you:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
What would you like God to do specifically for you?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Do you want to be free from your bad habits?
Do you want a normal relationship with your family?
Do you want to be forgiven for everything in the past?
Would you like to have a brand new start in life?
Do you want God to help you change?
Will you allow Him to let us help you change?
Financial Information
Income:
I am presently employed
I receive disability income
I receive retirement income
I receive SSI
I receive workman’s comp
I receive other unearned income
I receive food stamps
____Yes
____Yes
____Yes
____Yes
____Yes
____Yes
____Yes
____No
____No
____No
____No
____No
____No
____No
____Yes
____Yes
____Yes
____Yes
____Yes
____Yes
____No
____No
____No
____No
____No
____No
$__________ Monthly Income
$__________ Monthly Income
$__________ Monthly Income
$__________ Monthly Income
$__________ Monthly Income
$__________ Monthly Income
$__________ Monthly Income
Do you receive any other type of Government assistance? ____Yes
____No
If yes what type: _____________________________________________________
If yes what amount: $ _________________
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BREAK’N THE CHAINZ Of ADDICTIONS MINISTRIES, INC.
Confidential
I agree that all photos and videos taken of me while in Break’n The Chainz may be used on
websites, posters, newspapers etc. and I release the ministry to do so with no financial
obligation or responsibility to me.
I want to enter Break’n The Chainz’s program because: (use other sheets if necessary)
______________________________________________________________________________
______________________________________________________________________________
I feel the main issues I need to work on are:
______________________________________________________________________________
______________________________________________________________________________
I certify that all information here recorded is accurate and true to the best of my knowledge
and has been fully completed by me in my own hand. I fully understand that any false or
incomplete information may result in disqualification of any application for entrance.
Signed: ______________________________________________ Date: ____________________
If forms completed in part or in whole by anyone other than applicant:
Name: ___________________________________________ Relationship: _________________
Reason why applicant was unable to complete application for himself: _____________________
______________________________________________________________________________
Notice, it is hereby understood that Break’n the Chainz Ministries, Inc., will not be held
responsible for any personal property left, lost or stolen while in the Break’n The Chainz
program. I agree that any property left, lost or stolen while in the Break’n The Chainz Re-Entry
program after my departure date, voluntary or not, announced or unannounced becomes the
property of Break’n The Chainz Ministries, Inc. It is further understood that, I release Break’n
the Chainz Ministries, Inc., from all financial responsibilities in case of accident, injury, illness, or
other misfortune. I understand that there is a Five Hundred Dollar ($500.00) induction fee that
is payable upon entry into the program and is non-refundable. There are no refunds of any type
cards or cash whatsoever. I also understand that if I am dismissed from Break’n The Chainz
Ministries, Inc., or decide to leave the program I must leave immediately. If I become
belligerent, abusive, uncooperative or threatening I must leave the facility immediately. I also
understand that a failed toxicology is grounds for immediate dismissal, or admission to detox
center at the discretion of Break’n The Chainz Ministries, Inc. It is important that medical,
dental, business and legal needs be taken care of before entry into Break’n The Chainz
Ministries. If you have such needs that cannot be taken care of before entering Break’n The
Chainz Ministries, please call the admission office (508) 922-8351 and explain your situation.
Signed: _________________________________________________ Date: _________________
All items must be taken immediately upon leaving the program, anything left will be removed
Immediately with no liability to Break’n The Chainz of Addictions Ministries, Inc. (Revised 11/12)
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BREAK’N THE CHAINZ Of ADDICTIONS MINISTRIES, INC.
Confidential
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