Once we receive a copy of the application, you will be contacted to let you know if you qualify for the program. Depending on bed availability, you may be placed on a waiting list. You may contact us weekly to see how long you have to wait for a space to open up.
When you are contacted by our Intake Office please be prepared to give us a date as to when you expect to be here.
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Personal Information
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E-Mail:
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First Name:
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Last Name:
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Spouse Name:
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Date of Birth:
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MM/DD/YYYY
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Government ID & Type:
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ID Type, State, Number
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Social Security Number:
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Are you homeless?
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yes
no
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Address Line 1:
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Address Line 2:
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City:
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State:
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Zip Code:
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Day Phone:
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Evening Phone:
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Cell Phone:
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Fax:
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Age:
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Sex:
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Male
Female
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Height & Weight:
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Religion:
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Race/Ethnicity:
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Marital Status:
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Single
Married
Divorced
Widowed
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Emergency Contact Name:
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Relationship:
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Emergency Phone:
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Secondary Phone:
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Emergency Address:
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Do you have health insurance?
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Yes
No
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If yes, please provide the following:
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Provider Name:
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Policy Number:
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Group Number:
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Provider Phone Number:
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Do you have dental insurance?
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Yes
No
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If yes, please provide the following:
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Provider Name:
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Provider Name:
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Policy Number:
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Group Number:
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Provider Phone Number:
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Do you have a car?
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Yes
No
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If yes, who will take care of it while you are in the program?
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Are you currently receiving any type of income?
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Yes
No
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If yes, please explain:
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Have you ever been in the military?
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Yes
No
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Discharged?
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Yes
No
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If dishonorable discharge please explain:
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Education
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Select last year completed:
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Can you speak english?
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Yes
No
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Can you read and write?
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Yes
No
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Have you ever been in special education classes?
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Yes
No
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Religious Background
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Do you believe in God?
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Yes
No
Uncertain
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Have you ever accepted Jesus Christ as your Savior?
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Yes
No
Uncertain
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Are you attending church now?
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Yes
No
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If yes, where?
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Legal History
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Have you ever been arrested?
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Yes
No
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If yes, how many times?
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If yes, give details:
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Have you ever done jail time?
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Yes
No
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If yes, what for and how long?
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Are you on probation or parole?
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Yes
No
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If yes, give probation or parole officer's contact information below:
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Are you court ordered here?
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Yes
No
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If yes, give contact information regarding your court case:
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Do you have any legal charges pending?
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Yes
No
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If yes, where and what are the charges?
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Do you think you may have any outstanding warrants?
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Yes
No
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If yes, please explain:
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Do you have any other pending legal matters that would require you to attend to in the next 90 days?
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Yes
No
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If yes, give details:
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Drug History
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Have you ever used drugs?
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Yes
No
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If yes, how old were you?
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Why did you try them?
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Have you ever sold drugs?
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Yes
No
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Do you think you have a problem with drugs?
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Yes
No
Uncertain
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Explain why or why not:
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Since you've been using, what's the longest period of time that you've been sober?
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How long?
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Please fill out information below concerning your drug use.
Four boxes will be provided. Please tell us:
1. First Time - (How old you were or what month/year)
2. Last Time - (Approximate date)
3. Frequency - (How often did you use: occasionally, monthly, weekly, daily, etc.)
4. Amount Used - (How much did you use per day/week/month)
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Drug
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First Time
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Last Time
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Frequency
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Amount Used
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Alcohol:
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Barbiturates:
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Benzodiazepines:
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Cocaine/Crack:
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Glue/Paint:
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Heroin:
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Inhalants(Snuffing):
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LSD:
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Marijuana:
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MDMA (Ecstacy):
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Meth:
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Mushrooms:
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PCP:
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Prescription Drugs:
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Speed:
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Tobacco:
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Other:
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Medical History
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Date of last physical exam:
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results:
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List any physical ailments or handicaps that you may have:
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Date of last dental exam:
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results:
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List any dental problems you may have:
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Date of last eye exam:
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reslults:
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Do you wear glasses?
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Yes
No
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Do you wear contacts?
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Yes
No
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List anything that you may be allergic to:
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Please answer the medical questions below. If you answer yes to any of the questions, please use the box provided for the date of diagnosis.
Have you ever been:
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Diagnosed with ADD?
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Yes
No
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*
when?
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Diagnosed with ADHD?
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Yes
No
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*
when?
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* Diagnosed with any Mental Disorder?
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Yes
No
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*
when?
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* Diagnosed with Tuberculosis?
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Yes
No
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*
when?
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Diagnosed with Hepatitis A?
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Yes
No
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*
when?
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Diagnosed with Hepatitis B?
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Yes
No
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*
when?
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Diagnosed with Hepatitis C?
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Yes
No
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*
when?
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Diagnosed with HIV Positive?
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Yes
No
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*
when?
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Diagnosed with AIDS?
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Yes
No
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*
when?
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Diagnosed with Herpes?
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Yes
No
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*
when?
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Diagnosed with any STD?
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Yes
No
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*
when?
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Diagnosed with Body Lice?
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Yes
No
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*
when?
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Diagnosed with High Blood Pressure?
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Yes
No
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*
when?
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Diagnosed with Heart Attack/Disease?
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Yes
No
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*
when?
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Diagnosed with Cancer?
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Yes
No
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*
when?
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Diagnosed with any Stomach Disorder?
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Yes
No
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*
when?
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Diagnosed with Diabetes?
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Yes
No
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*
when?
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Diagnosed with a Stroke?
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Yes
No
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*
when?
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Diagnosed with any other illnesses?
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Yes
No
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*
when?
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Prone to seizures?
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Yes
No
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*
when?
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Do you have any chronic conditions not listed above that require regular Dr. visits?
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Yes
No
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If yes, please explain:
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Are you presently on any medication?
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Yes
No
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If yes, please list below and give reason for taking it:
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Have you ever been admitted to a hospital?
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Yes
No
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If yes, please explain:
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Are you physically able to perform all assignments (you must be able to lift 25 lbs, be able to stand for long periods of time as well as climb up to 4 flights of stairs) as part of this program?
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Physically able?
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Yes
No
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If no, please explain:
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Have you ever had any type of counseling?
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Yes
No
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If yes, please state how long and for what purpose?
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Have you ever been diagnosed with any mental condition?
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Yes
No
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If yes, please explain:
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Have you ever been under psychiatric care or been admitted to a mental health institution?
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Yes
No
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If yes, please explain:
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Sexual History
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Are you sexually active?
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Yes
No
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At what age did you become sexually active?
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How many sexual partners have you had?
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Have you ever had unprotected sex?
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Yes
No
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Have you ever contracted a sexually transmitted disease?
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Yes
No
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If yes, please list disease, when and how it was treated:
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Have you ever been the victim of sexual abuse?
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Yes
No
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If female, are you currently pregnant?
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Yes
No
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Have you been pregnant in the past?
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Yes
No
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If yes, what was the result of the pregnancy?
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Miscarriage
Abortion
Birth
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Do you have any children?
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Yes
No
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If yes, how many and what are their ages?
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Have you ever been involved in prostitution?
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Yes
No
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Have you ever been involved in any homosexual behavior or activities?
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Yes
No
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Do you consider yourself to be:
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Heterosexual (straight)
Bisexual
Homosexual (Gay/Lesbian)
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Goals
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What goals do you have while in this program?
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What do you want to happen in your life while you are in this program?
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How did you hear about us? (Check all of that apply)
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Friend:
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Family Member:
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Church Leader:
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Dream Center TV Show:
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Dream Center Website:
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Brochure/Flyer:
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Other:
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Disciple Agreement, Release Statement & Quick Test
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Click this link to download the Disciple Agreement, Release Statement and Quick Test.
This portion needs to be faxed or mailed to:
DC Discipleship
Attn: Intake Office
2301 Bellevue Ave
Los Angeles, CA 90026
213-273-7227 fax
These forms must be signed and submitted to us before your application can be processed.
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@LADreamCenter
@MatthewBarnett