DATE: I. PERSONAL INFORMATION Name: SSN: Address: City: State: Zip: Phone: Date of Birth: Age: Occupation: Highest Grade Completed/College/Degree: Other skills/training: What tools can you use: Farm or shop equipment? Office equipment? Past jobs: Present monthly income (include social security): Referred here by: Relationship:. Person to notify in case of emergency: Name: Relationship to you: Phone: Work Phone: Who will sponsor you financially while you are at Our Master s Camp? Name: Relationship to you: Phone: Email: II. MILITARY SERVICE Have you ever been in the military service? YES NO Branch: Job Held: - 1 -
III. LEGAL HISTORY (Continue on another sheet if needed) Do you have pending charges or court cases? YES NO If yes, Date of Arrest: Upcoming Court Date(s): Charge(s): Attorney: Phone: Are you on: Probation Parole How long? Name of Officer: Location: Phone: Email: Have you EVER been arrested or in jail? YES NO Charge(s): When: Where: IV. PHYSICAL HEALTH Height: Weight Exercise Regularly? YES NO Rate your physical health (check one): Very Good Good Average Declining Other Are you under a Doctor s care for any reason: YES NO If Yes, explain: CIRCLE ALL HEALTH PROBLEMS YOU CURRENTLY HAVE OR HAVE HAD IN THE PAST: TB AIDS VD CANCER HYPOGLYCEMIA POOR EYESIGHT HEARING MENTAL ILLNESS COLITIS PNEUMONIA BRONCHITIS PROSTATE CIRRHOSIS ANEMIA LEUKEMIA ARTHRITIS TOOTHACHE KIDNEY GLAUCOMA DIABETES BACKACHE BLACKOUTS THYROID DIZZINESS NAUSEA ULCERS EPILEPSY OTHER - 2 -
Explain any current physical health issues: Are you currently taking any medication? YES NO 1 A B C D Medication Dosage Frequency Reason Taken 2 3 4 5 6 7 8 Do you have enough refills for the 90 day program? YES NO *** ALL MEDICATIONS (INCLUDING OTC MEDS) MUST BE APPROVED BY STAFF *** V. MENTAL HEALTH Have you ever been diagnosed with a mental illness? YES NO If so, what diagnosis and when: Have you ever had any psychotherapy or counseling? YES NO List counselor/therapist, reason seen, and dates: Have you ever had a severe emotional breakdown? YES NO Explain: - 3 -
Have you ever been a patient in a mental institution? YES NO Where: How long: Date of Discharge: Explain: Are you having or have you ever had thoughts about hurting yourself? YES NO Explain: VI. RELATIONSHIP HISTORY Marital Status: Single: Married: Divorced: Widower: If currently married, Spouse: Phone: Date of Marriage: Have you ever been separated? YES NO Have you ever filed for divorce? YES NO When? Does she drink/use? YES NO Is spouse seeking help? YES NO Do you have any previous marriages? YES NO How many? Information about children: Name: Age: Sex: Education (grade/years) Are you responsible for paying child support? YES NO If yes, what arrangements have you made for your payment responsibilities? - 4 -
If you were raised by anyone other than your biological parents, briefly explain: Father: Living? YES NO Occupation: Mother: Living? YES NO Occupation: How may brothers and sisters do you have? Names: VII. RELIGIOUS BACKGROUND Are you a church member? YES NO Church: Pastor s Name: Phone: Denominational preference: How often do you attend church: Never Rarely Sometimes Often Do you believe in God? YES NO UNCERTAIN How often do you pray? Never Rarely Sometimes Often How often do you read the Bible? Never Rarely Sometimes Often Are you saved? YES NO NOT SURE Have you been baptized? YES NO AT WHAT AGE? Explain where you are spiritually: VIII. ADDICTION HISTORY Do you believe you have a substance abuse problem? YES NO - 5 -
Please fill out the following chart: Age @ Current Use Substance First Use Became Problematic Amount Frequency Alcohol Marijuana Cannabis, Weed Cocaine Crack, Powder Amphetamines Meth, Ice, Adderall Hallucinogens Mushrooms, LSD Heroin Methodone Opiates Oxy, Pain Pills Benzodiazipine Xanax, Valium Buprenorphine Suboxone, Subutex Synthetics Bath Salts, Spice If you ve used anything else please list: - 6 -
Have you ever been in any type of treatment for substance abuse : YES NO If so, list program, entry date, and length of stay: What is your longest period of sobriety? When: IX. BRIEFLY ANSWER THE FOLLOWING QUESTIONS A. What do you see as your main problem(s)? B. What have you tried to do about it? C. Why do you want to come to Our Master s Camp? 1. After submitting this application, please call to schedule a phone interview. 2. Work on completing the necessary blood work (HIV, HEP A, B, C, TB) 3. If not already, GET DETOXED, we cannot admit you until after you have detoxed. We look forward to helping you. - 7 -