Adult and Teen Challenge Screening Form
Please fill out the form truthfully and thoroughly.  All responses are confidential. 
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First and Last Name *
Email Address *
Cell Phone Number *
Address *
Date of Birth *
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What program are you interested in?  *
Are you pregnant? *
Are you bringing children with you? *
If yes, what are the age(s) of your child(ren)? 
What is your current life-controlling problem?   *
Required
Do you have an emotional or mental diagnosis? If so, please list diagnosis. *
List medications are you on. *
Are you incarcerated?  *
Are you on probation? *
If you have a substance problem, when did you last use?  *
If you have a substance abuse problem, have you been through detox recently?   *
I reviewed the website and have a good understanding of the program. *
List any extra info about you and your story or specific questions you want answered over the phone here.  *
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