Regeneration Program Application
Please fill out this form and click submit.
Personal Information
Name
*
Address
*
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AA
AB
AE
AK
AL
AP
AR
AS
AZ
BC
CA
CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MB
MD
ME
MH
MI
MN
MO
MP
MS
MT
NB
NC
ND
NE
NH
NJ
NL
NM
NS
NT
NU
NV
NY
OH
OK
ON
OR
PA
PE
PR
PW
QC
RI
SC
SD
SK
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
YT
Cell Phone
*
Alternate Phone Number
Date of Birth
*
Age
*
Emergency Contact Name
*
Emergency Contact Phone Number
*
Emergency Contact Address
*
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AA
AB
AE
AK
AL
AP
AR
AS
AZ
BC
CA
CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MB
MD
ME
MH
MI
MN
MO
MP
MS
MT
NB
NC
ND
NE
NH
NJ
NL
NM
NS
NT
NU
NV
NY
OH
OK
ON
OR
PA
PE
PR
PW
QC
RI
SC
SD
SK
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
YT
Emergency Contact Relationship to you
*
Parents
*
Please select all that apply.
Married
Separated
Widowed
Divorced
Never married
Not sure
Number of Siblings
*
Please select all that apply.
1-3
4-6
7-9
more than 9
Are you receiving an income?
*
Please select one option.
yes
no
Do you receive any of the following?
*
Please select all that apply.
Social Security
Disability
Income from a job
Money from a law suit
Other
Do you own
*
Please select all that apply.
vehicle
house
property
none
If you own a car please specify model and year
Do you currently have money?
*
Please select one option.
yes
no
Do you possess a valid driver's license?
*
Please select one option.
no
yes
suspended
DUI
Never had one
Program History
Have you attended a rehabilitation program before?
*
Please select one option.
yes
no
Name of program(s) or type NA if you did NOT attend
*
Date you attended 1st program
Did you complete the program?
*
Please select one option.
yes
no
never attended one before
Date you attended 2nd program
Did you complete the program?
*
Please select one option.
yes
no
never attended
Date you attended 3rd program
Did you complete the program?
*
Please select one option.
yes
no
never attended
Date you attended 4th program
Did you complete the program?
*
Please select one option.
yes
no
never attended
Marital Status
Are you
*
Please select all that apply.
married
single
divorced
separated
widowed
If married, what is your wife's name?
Wife's Date of Birth
Wife's address:
How long have you been married?
What is your wife's occupation?
What is your wife's income?
If divorced, how long have you been divorced?
If separated, how long have you been separated?
Reason for separation or divorce?
How many times have you been married?
*
Please select all that apply.
none
once
twice
three times
more than three
If widowed, when did your wife die and how?
Are you making payments for
*
Please select all that apply.
child support
alimony
none
How much do you pay a month in child support or alimony? If none please type none.
*
Please list the names and ages of each of your children.
*
Where do your children currently live and with whom do they live?
*
Education
Education Completed check all that apply
*
Please select all that apply.
High School Diploma
GED
Some high school
Trade School
AA or AS degree
BA or BS degree
Master's or higher
Some college
Please list the name of the college(s) or trade school(s) you attended and what degree you received.
Occupational Experience
Are you working now?
*
Please select one option.
yes
no
If you selected yes, please list the name of the company and what you do.
If you selected no, why not?
Please list any special skills or trades you can do:
*
Have you ever been fired from a job or alcohol or substance abuse?
*
Please select all that apply.
yes
no
received a warning
Have you ever quit a job because of alcohol or substance abuse?
*
Please select all that apply.
yes
no
Number of jobs you have held in the past five years:
*
Please select all that apply.
0-1
2-3
4-5
6-7
7-8
8-9
10 or more
What is the longest you have held a job?
*
Military Experience
Are you a veteran?
*
Please select one option.
yes
no
Were you discharged?
Please select all that apply.
yes
no
honorably discharged
Have you ever been court martialed?
Please select all that apply.
yes
no
If yes, please explain:
How long did you serve? What branch did you serve?
Did you retire from the military?
Please select all that apply.
yes
no
Personnel Background
What is your height and weight?
*
What is the current state of your health?
*
Please select one option.
Excellent
Good
Fair
Poor
Declining
List recent illnesses or operations:
*
Are you handicapped or disabled?
*
Please select all that apply.
yes
no
Please explain any handicaps or disabilities
If you use tobacco products, are you willing to give it up to attend Refuge on the Ridge?
*
Please select one option.
yes
no
I do not use tobacco
Have you ever been hospitalized for alcohol or drug addiction?
*
Please select one option.
yes
no
If yes, when and for what reason?
Have you ever suffered from depression?
*
Please select one option.
yes
no
occasionally
If yes or occasionally, please explain:
Have you ever had any thoughts of suicide?
*
Please select one option.
yes
no
If yes, please explain:
Have you ever attempted suicide?
*
Please select one option.
yes
no
If yes, please explain when and how you attempted:
Have you ever been treated for a psychiatric illness?
*
Please select one option.
yes
no
If yes, explain what illness and the treatment you received:
Alcohol and Drug History
What was your alcohol of choice prior to being accepted for this interview?
*
Please select all that apply.
Whiskey
Beer
Liquor
None, drugs were my main problem
How much would you drink a day?
*
How many years have you drank alcohol?
*
What drugs were you using prior to this interview?
*
Please select all that apply.
Weed
Opiods: heroin, suboxen, dope, opium, etc
Stimulants: crack, cocaine, meth, speed, etc.
Club Drugs: Roofies, Ecstasy, etc
Hallucinogens
Steroids
Inhalants
Other
Just alcohol
How many years have you been using drugs?
*
How much were you using per day?
*
What was the age and circumstances of your first drug or alcohol use?
*
Has your drinking or drug use pattern changed?
*
Please select one option.
yes
no
Please explain your past pattern of drug or alcohol abuse.
*
Have you ever tried to control your drinking or drug use?
*
Please select one option.
yes
no
If yes, how did you try to control it?
Have you ever had
*
Please select all that apply.
blackouts
seizures
tremors
DT's
None of the above
What was your drinking or drug behavior?
*
Please select all that apply.
Aggressive
Calm
Abusive
Quiet
Happy
Angry
What is your longest period of sobriety in the past two years?
*
Have you ever misused or abused prescription drugs?
*
Please select one option.
yes
no
If yes, what drugs did you misuse?
Have you ever misused or abused any drug NOT listed in the past to change your mood or get high?
*
Please select one option.
yes
no
If yes, what did you misuse?
Legal and Arrest Record
How many times have you been arrested?
*
Please select one option.
1-2
3-4
5-6
7-8
9-10
10 or more
Select Option
1-2
3-4
5-6
7-8
9-10
10 or more
What is the longest time you spent in jail?
*
List any felonies
List any misdemeanors
Are you currently involved in any lawsuits?
*
Please select one option.
yes
no
Has your driver's license ever been suspended or revoked?
*
Please select one option.
no
yes
If yes, why was it suspended or revoked?
Have you ever been to prison?
*
Please select one option.
no
yes
If yes, when?
If yes, where?
If yes, why?
Are there any charges pending against you now?
*
Please select one option.
yes
no
If yes, explain
Do you have any court dates pending now?
*
Please select one option.
yes
no
If yes,when?
Do you have any objections to us notifying the law that you are here?
*
Please select one option.
no
yes
Are you currently on probation or community control?
*
Please select one option.
yes
no
If yes, what is your probation/community control officer's name?
What county is the officer located in?
What is their phone number?
Religious Background
Are you a member of a church?
*
Please select one option.
yes
no
If yes, what is the name of the church?
If yes, what denomination is your church?
What city and state is the church located in?
What is the Pastor's name?
How often do you attend?
Have you ever served in church as a leader, teacher, greeter, singer, etc?
*
Please select one option.
yes
no
If yes, what did you do?
When did you last attend church?
*
How often do you read the Bible?
*
Do you ever pray?
*
Please select one option.
yes
no
If you pray, when do you pray?
Are you saved?
*
Please select one option.
yes
no
If you are married what is the religious background of your wife?
How did you hear about Refuge on the Ridge?
*
Submit
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