Student Application

Application

Date

MM slash DD slash YYYY
Patient First Name
Patient Last Name
DOB

MM slash DD slash YYYY
Age
Address

Street Address

Address Line 2

City

State

ZIP Code
SS#
Expected to Enroll
Parent / Guardian / Sponsor Info
Parent / Guardian / Sponsor (PRIMARY)

First Name Last Name Relationship Address Home Phone Mobile Phone Email Preferred Method of Contact
Parent / Guardian / Sponsor (PRIMARY) 2

First Name Last Name Relationship Address Home Phone Mobile Phone Email Preferred Method of Contact
Parent / Guardian / Sponsor (PRIMARY) 3

First Name Last Name Relationship Address Home Phone Mobile Phone Email Preferred Method of Contact
Parent / Guardian / Sponsor (PRIMARY) 4

First Name Last Name Relationship Address Home Phone Mobile Phone Email Preferred Method of Contact
Referral Information
How did you first hear about Teen Challenge Adventure Ranch?
Please give the name(s) of the referral source
What is leading you to seek treatment for your child at this time? Describe your child's current difficulties and note when these behaviors/issues recently escalated. Please be very specific and include dates when possible.
General Information
Is the applicant fluent in any languages other than English? (If yes, specify)
Ethnicity
Hair Color
Eye Color
Shirt Size
Shoe Size
Waist
Length
Height
Weight
Scars or Tattoos/Other Distinguishing Marks (if yes, describe)
Has your child ever been employed? (If yes, where, when and please list circumstances leading to termination, if applicable)
Parent / Guardian Report
How motivated is your child for recovery?
Comment on any factors that may have contributed to the problems that your child is having
Please describe what steps you have taken so far to help your child
Teen Challenge hosts six mandatory family events each year.
This is for parents only and if there are two parents in the home, both are required to attend.
I / we understand that there are required family events offered by Teen Challenge, and we plan to attend?
- Yes
- No
Family Information

Do not include extended family (I.e. grandparents or aunts and uncles) unless that family member has had guardianship or care of the child in the past. Please include adult children who live separately and parents that the child does not live with.
Family Information

Name Relationship to Student Age Household Status Substance User Mental Health Issues Allowed Contact
Family Information 2

Name Relationship to Student Age Household Status Substance User Mental Health Issues Allowed Contact
Family Information 3

Name Relationship to Student Age Household Status Substance User Mental Health Issues Allowed Contact
Family Information 4

Name Relationship to Student Age Household Status Substance User Mental Health Issues Allowed Contact
Family Information 5

Name Relationship to Student Age Household Status Substance User Mental Health Issues Allowed Contact
Family Information 6

Name Relationship to Student Age Household Status Substance User Mental Health Issues Allowed Contact
Students may receive correspondence from immediate family, pastors, teachers, and/or counselors. Please let us know who you would like your child to receive mail from.
Allowed Contacts

Name Relationship Mailing Address
Allowed Contacts 2

Name Relationship Mailing Address
Allowed Contacts 3

Name Relationship Mailing Address
Allowed Contacts 4

Name Relationship Mailing Address
Describe any significant events in your child's life over the past 2 years that have contributed to their stress level (moves, separation, losses of loves ones, etc)
Has the applicant been raised by anyone other than his parents? (If yes, please explain)
Describe any history of abuse of neglect experienced (emotional, physical, and/or sexual)
Describe any additional experiences from you child's past that you think may have had an impact on their emotional well-being
Has Child Protective Services ever been involved? If yes, please describe, including date(s)
Was your child adopted? If yes, at what age?
List any known information about bio-parents
Has you child ever been placed outside of the home? (Dates and circumstances)
Describe the relationship between your child and...
Mother
Father
Guardian
Siblings (Include names / ages)
Is there any current or past history of mental health or substance related disorders? (If yes, please describe)
Is there any current or past family history of medical issues?
Are you currently married?
Please describe the conditions of your current marriage
Is there a separation or divorce pending?
Please describe the divorce dynamics that may have had an impact on your child
A copy of the divorce decree and custody arrangements will need to be submitted to Teen Challenge with these forms
Does your family attend church regularly, or are faith observant?
What is your religious / denominational preference?
Name of church and how often you attend on average
What are your child's religious/spiritual beliefs
Are these beliefs / practices a significant part of their life?
Is there a cultural history that influences you child's life
Are there any cultural, racial, or ethnic background issues that will impact treatment
Legal History
Has the student ever been arrested?
- Yes
- No
If yes, explain with details
Please give number of, dates of, city and state, reason for and disposition of arrest(s)

Number of Dates of City State Reason for Disposition of arrest(s)
Please give number of, dates of, city and state, reason for and disposition of arrest(s) 2

Number of Dates of City State Reason for Disposition of arrest(s)
Please give number of, dates of, city and state, reason for and disposition of arrest(s) 3

Number of Dates of City State Reason for Disposition of arrest(s)
Please give number of, dates of, city and state, reason for and disposition of arrest(s) 4

Number of Dates of City State Reason for Disposition of arrest(s)
Pending charges? (Include charge and court date)

Charge Court Date
Pending charges? (Include charge and court date) 2

Charge Court Date
Pending charges? (Include charge and court date) 3

Charge Court Date
Pending charges? (Include charge and court date) 4

Charge Court Date
Has the student ever been convicted? (Please provide details)
Is the student under a FINS petition?
- Yes
- No
Is the student on probation?
- Yes
- No
Probation Officer Contact Information

P.O. Name Address Phone Email
Probation Officer Contact Information 2

P.O. Name Address Phone Email
Please provide information about any other illegal activity that you feel Teen Challenge Adventure Ranch chould know about your child
Issues Assessment: What is leading you to seek treatment for your child at this time? Describe your child's current difficulties and note when these behaviors / issues recently escalated. Please be very specific and include dates if when possible.
For example: drug/alcohol abuse, anxiety, anger, depression, self-mutilation, pornography, self-image, suicidal/homicidal thoughts, etc.
Issues
- Drug Abuse
- Death of a Loved One
- Fear
- Pornography
- Hearing Voices
- Running Away
- Tobacco
- Family Relationships
- Insomnia
- Hallucinations
- Physical Abuse
- Abandonment
- Depression
- Forgiveness Issues
- Suicidal Thoughts
- Alcohol Abuse
- Emotional Stress
- Sexual Abuse
- Guilt
- Aggressive/Violent Behavior
- Anxiety
- Anger
- Self-Mutilation
- Self Image
- Arson/Fire Starting
- Paranoia
Please explain in detail anything checked above

Issue Details
Please explain in detail anything checked above 2

Issue Details
Please explain in detail anything checked above 3

Issue Details
Please explain in detail anything checked above 4

Issue Details
Please explain in detail anything checked above 5

Issue Details
Please explain in detail anything checked above 6

Issue Details
Please explain in detail anything checked above 7

Issue Details
Please explain in detail anything checked above 8

Issue Details
Please explain in detail anything checked above 9

Issue Details
Please explain in detail anything checked above 10

Issue Details
Describe any history of suicidal thoughts or car wrecks, over dose, etc.
Past Suicide Attempts?
- Yes
- No
Suicide Attempts: (Include date, method, if it required hospitalization, the lethality and any notes)

Date Method Required Hospitalization (Yes/No) Lethality Notes
Suicide Attempts: (Include date, method, if it required hospitalization, the lethality and any notes) 2

Date Method Required Hospitalization (Yes/No) Lethality Notes
Suicide Attempts: (Include date, method, if it required hospitalization, the lethality and any notes) 3

Date Method Required Hospitalization (Yes/No) Lethality Notes
Suicide Attempts: (Include date, method, if it required hospitalization, the lethality and any notes) 4

Date Method Required Hospitalization (Yes/No) Lethality Notes
Past Self-Injury?
- Yes
- No
Self-Injury: (Include date, method, if it required hospitalization, the lethality and any notes)

Date Method Required Hopsitalization (Yes/No) Lethality Notes
Self-Injury: (Include date, method, if it required hospitalization, the lethality and any notes) 2

Date Method Required Hopsitalization (Yes/No) Lethality Notes
Self-Injury: (Include date, method, if it required hospitalization, the lethality and any notes) 3

Date Method Required Hopsitalization (Yes/No) Lethality Notes
Self-Injury: (Include date, method, if it required hospitalization, the lethality and any notes) 4

Date Method Required Hopsitalization (Yes/No) Lethality Notes
Substance Abuse History
Please indicate any and all substances that you know your son has used. Include alcohol, amphetamines, barbiturates, crack, cocaine, ecstacy, heroin, huffing/snuffing, LSD, marijuana, methadone, methamphetamine, morphine, mushrooms, opioids, oxycontin, PCP, tobacco or any other substance and/or prescription medication.
Does your child have a history of using/abusing over-the-counter substances? If yes, please explain
Medical History
PAST Medications: Please indicate all medications including over the counter and supplements. PLEASE FILL OUT EVERY FIELD

Medication Dosage Frequency Reason for Med Length of Time on Med
PAST Medications: Please indicate all medications including over the counter and supplements. PLEASE FILL OUT EVERY FIELD 2

Medication Dosage Frequency Reason for Med Length of Time on Med
PAST Medications: Please indicate all medications including over the counter and supplements. PLEASE FILL OUT EVERY FIELD 3

Medication Dosage Frequency Reason for Med Length of Time on Med
PAST Medications: Please indicate all medications including over the counter and supplements. PLEASE FILL OUT EVERY FIELD 4

Medication Dosage Frequency Reason for Med Length of Time on Med
PAST Medications: Please indicate all medications including over the counter and supplements. PLEASE FILL OUT EVERY FIELD 5

Medication Dosage Frequency Reason for Med Length of Time on Med
PAST Medications: Please indicate all medications including over the counter and supplements. PLEASE FILL OUT EVERY FIELD 6

Medication Dosage Frequency Reason for Med Length of Time on Med
CURRENT Medications: Please indicate all medications including over the counter and supplements. PLEASE FILL OUT EVERY FIELD

Medication Dosage Frequency Reason for Med Length of Time on Med
CURRENT Medications: Please indicate all medications including over the counter and supplements. PLEASE FILL OUT EVERY FIELD 2

Medication Dosage Frequency Reason for Med Length of Time on Med
CURRENT Medications: Please indicate all medications including over the counter and supplements. PLEASE FILL OUT EVERY FIELD 3

Medication Dosage Frequency Reason for Med Length of Time on Med
CURRENT Medications: Please indicate all medications including over the counter and supplements. PLEASE FILL OUT EVERY FIELD 4

Medication Dosage Frequency Reason for Med Length of Time on Med
CURRENT Medications: Please indicate all medications including over the counter and supplements. PLEASE FILL OUT EVERY FIELD 5

Medication Dosage Frequency Reason for Med Length of Time on Med
CURRENT Medications: Please indicate all medications including over the counter and supplements. PLEASE FILL OUT EVERY FIELD 6

Medication Dosage Frequency Reason for Med Length of Time on Med
CURRENT Medications: Please indicate all medications including over the counter and supplements. PLEASE FILL OUT EVERY FIELD 7

Medication Dosage Frequency Reason for Med Length of Time on Med
Are medications taken as prescribed (on time, in the proper dosage)?
If No, when was the last time the med was taken and why:
Check all that apply to your son's current and past conditions
- None
- ADHD
- Bi-Polar
- Allergies/Asthma
- Head Trauma
- Mental Illness
- Lung Dysfunction
- Sexually Transmitted Disease(s)
- Knocked Unconscious
- Kidney Dysfunction
- Dental Problems
- Heart Dysfunction
- Positive TB Test
- Back Problems
- HIV
- Blood Disorder
- Schizophrenia
- Skin Infections
- Chronic Medial Problems
- Esophagus Dysfunction
- Vision Problems
- Eating Disorders
- Nervous Condition
- Multiple Personalities
- Diabetes
- Autism
- Seizures
- Infectious Disease(s)
- Liver Dysfunction
- Bruises Easily
- Hepatitis
- Other
Please explain and provide details about all items indicated above

Issue Explain with Details
Please explain and provide details about all items indicated above 2

Issue Explain with Details
Please explain and provide details about all items indicated above 3

Issue Explain with Details
Please explain and provide details about all items indicated above 4

Issue Explain with Details
Please explain and provide details about all items indicated above 5

Issue Explain with Details
Please explain and provide details about all items indicated above 6

Issue Explain with Details
Please explain and provide details about all items indicated above 7

Issue Explain with Details
Please explain and provide details about all items indicated above 8

Issue Explain with Details
Please explain and provide details about all items indicated above 9

Issue Explain with Details
Please explain and provide details about all items indicated above 10

Issue Explain with Details
Is your child able to participate in rigorous physical activities (I.e. sports, rappelling, hiking, running, etc.)? Please explain
Primary Care Physician (list name, address, phone number and date of last visit)

Name Address Phone Number Date of Last Visit
Primary Care Physician (list name, address, phone number and date of last visit) 2

Name Address Phone Number Date of Last Visit
Primary Care Physician (list name, address, phone number and date of last visit) 3

Name Address Phone Number Date of Last Visit
Please list all hospitalizations and/or ER visits (include what they were treated for, date(s) treated, length of stay, place of service/city/state

Treated for Date(s) Length of Stay Place of Service/City/State
Please list all hospitalizations and/or ER visits (include what they were treated for, date(s) treated, length of stay, place of service/city/state 2

Treated for Date(s) Length of Stay Place of Service/City/State
Please list all hospitalizations and/or ER visits (include what they were treated for, date(s) treated, length of stay, place of service/city/state 3

Treated for Date(s) Length of Stay Place of Service/City/State
Please list all hospitalizations and/or ER visits (include what they were treated for, date(s) treated, length of stay, place of service/city/state 4

Treated for Date(s) Length of Stay Place of Service/City/State
Developmental History
During pregnancy, was mother on prescribed or illegal drugs? If yes, please describe
Were there any complications during mother's pregnancy or delivery? If yes, please describe
Were there any special problems in the growth and development of the child during the first few weeks? If yes, please describe
Did your child reach milestones on time? If no, please describe
Is your child up to date on his vaccinations?
- Yes
- No
Does your child wear braces?
- Yes
- No
Does your child have any food, environmental or medication allergies? (If yes, please elaborate)
Does your child have an advance directive?
- Yes
- No
Testing and Diagnosis
Has your child ever received
- None
- Medical
- Psychological evaluations
- Psycho-educational assessments
- IQ testing
- Other
Comments/Additional information if applicable
Has your child been diagnosed with a psychological, behavioral, or development disorder? What were the resulting diagnosis?
Treatment / Placement History

Please include all previous counseling, inpatient, psychiatric, psychological, or any other professional services received
Previous Residential Treament?
- Yes
- No
Residential Treatment: List entry date, discharge date, agency or program and phone number, reason for treatment/placement, and results of placement/treatment

Date Discharge Data Agency/Program Phone Reason for Treatment Results of Treatment
Residential Treatment: List entry date, discharge date, agency or program and phone number, reason for treatment/placement, and results of placement/treatment 2

Date Discharge Data Agency/Program Phone Reason for Treatment Results of Treatment
Residential Treatment: List entry date, discharge date, agency or program and phone number, reason for treatment/placement, and results of placement/treatment 3

Date Discharge Data Agency/Program Phone Reason for Treatment Results of Treatment
Residential Treatment: List entry date, discharge date, agency or program and phone number, reason for treatment/placement, and results of placement/treatment 4

Date Discharge Data Agency/Program Phone Reason for Treatment Results of Treatment
Residential Treatment: List entry date, discharge date, agency or program and phone number, reason for treatment/placement, and results of placement/treatment 5

Date Discharge Data Agency/Program Phone Reason for Treatment Results of Treatment
Previous Outpatient Treatment?
- Yes
- No
Outpatient Treatment (Therapy/counseling/psychiatrist/PHP or IOP/GOP sessions): List entry date, discharge date, agency or program and phone number, reason for treatment / placement, and results of placement/treatment

Entry Date Discharge Date Agency/Program Phone Reason for Treatment Results of Treatment
Outpatient Treatment (Therapy/counseling/psychiatrist/PHP or IOP/GOP sessions): List entry date, discharge date, agency or program and phone number, reason for treatment / placement, and results of placement/treatment 2

Entry Date Discharge Date Agency/Program Phone Reason for Treatment Results of Treatment
Outpatient Treatment (Therapy/counseling/psychiatrist/PHP or IOP/GOP sessions): List entry date, discharge date, agency or program and phone number, reason for treatment / placement, and results of placement/treatment 3

Entry Date Discharge Date Agency/Program Phone Reason for Treatment Results of Treatment
Outpatient Treatment (Therapy/counseling/psychiatrist/PHP or IOP/GOP sessions): List entry date, discharge date, agency or program and phone number, reason for treatment / placement, and results of placement/treatment 4

Entry Date Discharge Date Agency/Program Phone Reason for Treatment Results of Treatment
Outpatient Treatment (Therapy/counseling/psychiatrist/PHP or IOP/GOP sessions): List entry date, discharge date, agency or program and phone number, reason for treatment / placement, and results of placement/treatment 5

Entry Date Discharge Date Agency/Program Phone Reason for Treatment Results of Treatment
Has your child ever relapsed in treatment, been discharged against medical advice, or left treatment early? Please explain
What are your child's strength needs and abilities?
Who does your child consider to be a part of their support network (family, friends, church, teachers, sponsor, etc.)
Are these individuals healthy and supportive of your child's recovery
Academic Information
Previous Schools: List most recent schools first: List each school name, dates attended, address, phone/fax, contact and email (if known):

School Name Dates Attended Phone/Fax Contact Email
Previous Schools: List most recent schools first: List each school name, dates attended, address, phone/fax, contact and email (if known): 2

School Name Dates Attended Phone/Fax Contact Email
Previous Schools: List most recent schools first: List each school name, dates attended, address, phone/fax, contact and email (if known): 3

School Name Dates Attended Phone/Fax Contact Email
Previous Schools: List most recent schools first: List each school name, dates attended, address, phone/fax, contact and email (if known): 4

School Name Dates Attended Phone/Fax Contact Email
Previous Schools: List most recent schools first: List each school name, dates attended, address, phone/fax, contact and email (if known): 5

School Name Dates Attended Phone/Fax Contact Email
What is the highest grade or degree completed
What is your child's current GPA and has this changed due to current issues
Does your child have any learning disabilities? If yes, please explain in detail
Do they or have they ever had an IEP or 504 plan? If yes, please specify and explain in detail
List any and all instances of detention, ISS, OSS or alternative school (dates and reason)
Insurance Information
Primary Insurance Company
Address
Benefits Phone
Group No.
Policy No.
Policyholder's First Name
Policyholder's Last Name
Employer
Policyholder's Date of Birth
SSN
Rx BIN
Rx PCN
Rx Grp
Pharmacy Help Desk Phone
Secondary Insurance Information (include all fields above)

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Application

Parent / Guardian / Sponsor Info

Referral Information

General Information

Parent / Guardian Report

Family Information

Describe the relationship between your child and...

Legal History

Substance Abuse History

Medical History

Developmental History

Testing and Diagnosis

Treatment / Placement History

Academic Information

Insurance Information

Phone

Fax: (888) 844-1669

Info

Therapeutic Program

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