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Programme Application Form
This information will be kept confidential.
OUR CENTRE IS FOR MEN ONLY.
If you are a woman seeking help please contact Hope House on 01269 844 114.
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* Indicates required question
Name
*
First and last name
Your answer
Present Address
*
Your answer
Post Code:
*
Your answer
Phone number
*
Your answer
Email
*
Your answer
Date of birth
*
MM
/
DD
/
YYYY
Nationality
*
Your answer
Birthplace
*
Your answer
Contact Name
*
Your answer
Contact Relationship
*
Your answer
Phone Number or Email
*
Your answer
Accommodation
*
Alone
Spouse
Parents
Friends
Other:
Do you own a house or flat?
*
Yes
No
Are you a council tenant?
*
Yes
No
Marital Status
*
Single
Married
Separated
Divorced
Widowed
Other:
Are you currently employed?
*
Yes
No
If yes, with whom?
Your answer
National Insurance Number (NINO)
*
Your answer
Benefits Claimed
None
Universal Credit
ESA
Other:
Clear selection
Employment History
Your answer
Do you smoke?
*
Yes
No
If yes, how many per day?
Your answer
Do you drink?
*
Yes
No
If yes, how much per day?
Your answer
Do you use drugs?
*
Yes
No
If yes, what is you primary drug?
Your answer
Other drugs used:
*
Amphetamines
Cannabis
Crack Cocaine
Ecstacy
Heroin
LSD
Methadone
Temazepam
Other:
Required
Are you taking prescribed medication?
*
Yes
No
If yes, what medication?
Your answer
Do you require a medical detox?
*
Yes
No
Have you received any previous treatment for drug or alcohol abuse?
*
Yes
No
If yes, with whom?
Your answer
Have you ever been on a Teen Challenge programme before?
*
Yes
No
If yes, when and at which centre?
Your answer
Have you ever breached the terms of a tenancy for which there were statutory grounds for possession, or breached the terms of a mortgage?
*
Yes
No
Have you ever committed acts of physical violence against staff or other residents in a place where you were living?
*
Yes
No
Who has provided support for you over the past two years (e.g. professionals, workers, voluntary or religious organisations, family)?
*
Your answer
Does a social worker or drug/alcohol agency support you?
*
Yes
No
Have you ever seen a psychiatrist?
*
Yes
No
Have you ever experienced mental or emotional health problems?
*
Yes
No
If yes, when and provide your doctor's details.
Your answer
GP's Name
*
Your answer
GP's Address & phone number:
*
Your answer
Do you have any ongoing health issues?
*
Yes
No
If yes, please describe.
Your answer
Do you have a criminal record?
*
Yes
No
If yes, please give details of any criminal convictions.
Your answer
Do you have a probation officer?
*
Yes
No
Do you have any outstanding warrants?
*
Yes
No
Do you have any outstanding court appearances?
*
Yes
No
Have you ever been prosecuted for a violent offence?
*
Yes
No
Have you ever been prosecuted for a sexual offence?
*
Yes
No
Have you ever been prosecuted for arson?
*
Yes
No
Are you subject to any form of statutory supervision or probation?
*
Yes
No
Please tell us why you want to come to Teen Challenge London:
*
Your answer
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