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Student Application

Application

  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • Parent / Guardian / Sponsor Info

  • First NameLast NameRelationshipAddressHome PhoneMobile PhoneEmailPreferred Method of Contact
  • First NameLast NameRelationshipAddressHome PhoneMobile PhoneEmailPreferred Method of Contact
  • First NameLast NameRelationshipAddressHome PhoneMobile PhoneEmailPreferred Method of Contact
  • First NameLast NameRelationshipAddressHome PhoneMobile PhoneEmailPreferred Method of Contact
  • Referral Information

  • General Information

  • Parent / Guardian Report

  • 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.
  • 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.
  • NameRelationship to StudentAgeHousehold StatusSubstance UserMental Health IssuesAllowed Contact
  • NameRelationship to StudentAgeHousehold StatusSubstance UserMental Health IssuesAllowed Contact
  • NameRelationship to StudentAgeHousehold StatusSubstance UserMental Health IssuesAllowed Contact
  • NameRelationship to StudentAgeHousehold StatusSubstance UserMental Health IssuesAllowed Contact
  • NameRelationship to StudentAgeHousehold StatusSubstance UserMental Health IssuesAllowed Contact
  • NameRelationship to StudentAgeHousehold StatusSubstance UserMental Health IssuesAllowed 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.
  • NameRelationshipMailing Address
  • NameRelationshipMailing Address
  • NameRelationshipMailing Address
  • NameRelationshipMailing Address
  • Describe the relationship between your child and...

  • A copy of the divorce decree and custody arrangements will need to be submitted to Teen Challenge with these forms
  • Legal History

  • Number ofDates ofCityStateReason forDisposition of arrest(s)
  • Number ofDates ofCityStateReason forDisposition of arrest(s)
  • Number ofDates ofCityStateReason forDisposition of arrest(s)
  • Number ofDates ofCityStateReason forDisposition of arrest(s)
  • ChargeCourt Date
  • ChargeCourt Date
  • ChargeCourt Date
  • ChargeCourt Date
  • P.O. NameAddressPhoneEmail
  • P.O. NameAddressPhoneEmail
  • 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.
  • IssueDetails
  • IssueDetails
  • IssueDetails
  • IssueDetails
  • IssueDetails
  • IssueDetails
  • IssueDetails
  • IssueDetails
  • IssueDetails
  • IssueDetails
  • DateMethodRequired Hospitalization (Yes/No)LethalityNotes
  • DateMethodRequired Hospitalization (Yes/No)LethalityNotes
  • DateMethodRequired Hospitalization (Yes/No)LethalityNotes
  • DateMethodRequired Hospitalization (Yes/No)LethalityNotes
  • DateMethodRequired Hopsitalization (Yes/No)LethalityNotes
  • DateMethodRequired Hopsitalization (Yes/No)LethalityNotes
  • DateMethodRequired Hopsitalization (Yes/No)LethalityNotes
  • DateMethodRequired Hopsitalization (Yes/No)LethalityNotes
  • Substance Abuse History

  • Medical History

  • MedicationDosageFrequencyReason for MedLength of Time on Med
  • MedicationDosageFrequencyReason for MedLength of Time on Med
  • MedicationDosageFrequencyReason for MedLength of Time on Med
  • MedicationDosageFrequencyReason for MedLength of Time on Med
  • MedicationDosageFrequencyReason for MedLength of Time on Med
  • MedicationDosageFrequencyReason for MedLength of Time on Med
  • MedicationDosageFrequencyReason for MedLength of Time on Med
  • MedicationDosageFrequencyReason for MedLength of Time on Med
  • MedicationDosageFrequencyReason for MedLength of Time on Med
  • MedicationDosageFrequencyReason for MedLength of Time on Med
  • MedicationDosageFrequencyReason for MedLength of Time on Med
  • MedicationDosageFrequencyReason for MedLength of Time on Med
  • MedicationDosageFrequencyReason for MedLength of Time on Med
  • IssueExplain with Details
  • IssueExplain with Details
  • IssueExplain with Details
  • IssueExplain with Details
  • IssueExplain with Details
  • IssueExplain with Details
  • IssueExplain with Details
  • IssueExplain with Details
  • IssueExplain with Details
  • IssueExplain with Details
  • NameAddressPhone NumberDate of Last Visit
  • NameAddressPhone NumberDate of Last Visit
  • NameAddressPhone NumberDate of Last Visit
  • Treated forDate(s)Length of StayPlace of Service/City/State
  • Treated forDate(s)Length of StayPlace of Service/City/State
  • Treated forDate(s)Length of StayPlace of Service/City/State
  • Treated forDate(s)Length of StayPlace of Service/City/State
  • Developmental History

  • Testing and Diagnosis

  • Treatment / Placement History

    Please include all previous counseling, inpatient, psychiatric, psychological, or any other professional services received
  • DateDischarge DataAgency/Program PhoneReason for TreatmentResults of Treatment
  • DateDischarge DataAgency/Program PhoneReason for TreatmentResults of Treatment
  • DateDischarge DataAgency/Program PhoneReason for TreatmentResults of Treatment
  • DateDischarge DataAgency/Program PhoneReason for TreatmentResults of Treatment
  • DateDischarge DataAgency/Program PhoneReason for TreatmentResults of Treatment
  • Entry DateDischarge DateAgency/Program PhoneReason for TreatmentResults of Treatment
  • Entry DateDischarge DateAgency/Program PhoneReason for TreatmentResults of Treatment
  • Entry DateDischarge DateAgency/Program PhoneReason for TreatmentResults of Treatment
  • Entry DateDischarge DateAgency/Program PhoneReason for TreatmentResults of Treatment
  • Entry DateDischarge DateAgency/Program PhoneReason for TreatmentResults of Treatment
  • Academic Information

  • School NameDates AttendedPhone/FaxContactEmail
  • School NameDates AttendedPhone/FaxContactEmail
  • School NameDates AttendedPhone/FaxContactEmail
  • School NameDates AttendedPhone/FaxContactEmail
  • School NameDates AttendedPhone/FaxContactEmail
  • Insurance Information

Should you need help finding Christian boarding schools, therapeutic boarding schools, Christian boarding schools, military academies, or boys homes, please let us know. Teen Challenge Adventure Ranch is a Christian therapeutic boarding school and boys home. Boys come to our therapeutic school and home in Northwest Arkansas from across the United States. We help at-risk boys who struggle with behavioral issues. Therapeutic boarding schools and boys homes like Teen Challenge offer behavioral therapy and a rehab for troubled teen boys with teen counseling for boys.

Student Application

If your son is struggling with life-controlling issues, fill out an application for Teen Challenge Adventure Ranch in Arkansas.

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