Online Application
Freedom From Addiction Starts Here

GENERAL

Social media, website, friend, etc.
Please give us their name, phone and address (Relationship - Friend, Relative, etc)

PERSONAL

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With Whom? Where?

MARITAL STATUS

DRUG HISTORY

LEGAL HISTORY

SPIRITUAL STATUS

FINANCIAL STATUS

THE PRESENTING PROBLEM

HEALTH STATUS

(You MUST Have All The Necessary Dental Work Completed BEFORE Coming Into Adult & Teen Challenge MidSouth. Unless Something Arises Of An Emergency Nature, You Will Not Be Taken To A Dentist While In Adult & Teen Challenge Midsouth)

Adult & Teen Challenge MidSouth Dental/Medical/Drug Withdrawal Policy

Due to the fact that Adult & Teen Challenge MidSouth is NOT a medical facility, the following policies have been enacted:

DENTAL:

It is STRONGLY ADVISED that residents get a dental check-up prior to entering the program! Residents enrolled in our program WILL NOT have access to a dentist for at least 4 months except for emergencies. In the event of an emergency, the resident’s family will be responsible for any medical costs. If a resident in the program requires on-going dental treatment, they will be required to take a leave of absence. Once the work is completed and we receive verification, they can return to the program.

MEDICAL:

Residents will only have access to medical care in case of emergencies. Residents that have a pre-existing condition or a condition that develops while enrolled in the program which requires on-going medical treatment will be required to take a leave of absence. We must receive medical release/ verification before they can return to the program.

DRUG/ALCOHOL WITHDRAWAL:

Due to the fact that some withdrawal symptoms are unpleasant but some can be FATAL, severe alcoholics and those taking certain medications may require a physician’s statement that you have gone through a detox process or that you have been weaned off the medication under their supervision. If you enter the program but are not able to participate due to drug or alcohol withdrawal for more than 1-2 days, you will be required to take a leave of absence and go through a medically supervised detox. To return to the program, you would need to provide medical verification that you have done so.

I Have Read And Understood The Above Policies

RELEASE OF INFORMATION

VERY IMPORTANT: This release of Information document informs Adult & Teen Challenge MidSouth of any person that you want informed of your intent to enter the program, or who may be involved in your intake process. The information exchanged with these people may be utilized to determine your eligibility for the program. This release shall also extend to the development and revision of my treatment plan while enrolled in the program as well as making the transition back to normal life after the program. Because of Federal confidentiality laws, you must list, EVERY person, even immediate family members, that are to be informed of your intent or may be involved in the intake process. In short, if a person’s name is not on the list, we will not be allowed to communicate with them or even acknowledge the receipt of an application, regardless of who they are or their relationship to you. The ONLY exception to this will be in accordance with Federal guidelines.
*This consent is subject to revocation in writing by the resident at any time except to the extent that the ministry or person who is to make the disclosure has already acted on it. This consent automatically expires one year and six months from the date it is signed.
AFTER SUBMITTING THIS FORM, PLEASE READ AND CLICK ON THE CONFIRMATION POP UP WINDOW FOR REQUIRED READING DOCUMENTS.