Regeneration Program Application

A. BASIC INFORMATION

Name

Middle

Nickname

Phone

Are you homeless

Yes No

Address

Birthdate

Place of Birth

Social Security#

B. EMERGENCY CONTACT INFORMATION

Emergency Notification

Emergency Notification Phone #

Emergency Notification Address

Emergency Notification Relationship

C. FAMILY BACKGROUND

Number of Brothers

Number of Sisters

Your postion in your family

Parents' Name(s) (if living)

Parents' Address

Are your parents

If divorced, what was the reason?

Is either parent deceased?

Father Mother Both Neither

If deceased, when did they die?

Do you own

A home Property Vehicle Nothing

If you own a vehicle, what is the model and year of vehicle?

Are you receiving any other form or source of income? (Disability, civil suits, etc)

If yes, how much do you receive?

Do you currently have any money on you?

If yes, how much money do you have on you?

Do you posses a valid driver's license?

If yes, what is your DL #

If yes, what state is your DL issued?

If yes, what type or class is it?

D. PROGRAM HISTORY

Have you ever attended any other rehabilitation centers?

If yes, Please provide the name of other programs, when you attended, and if you completed the program or not:

Have you ever attended AA or NA

AA NA Neither

If yes, when did you attend and for how long?

C. MARITAL STATUS

Are you

Single Married Separated Divorced Widowed

If you are single, and have never been married before please skip to section D.

If married, what is your wife's full name?

If married, what is your wife's date of birth?

If married, what is your wife's address

If married, how long have you been married?

If separated, how long have you been separated? And what is the reason for separation?

If divorced, how long have you been divorced? And what was the reason for the divorce?

If divorced, has your ex wife remarried?

Number of times you have been married?

When were you married the first time?

When were you divorced the first time?

Reason for first divorce?

When were you married the second time?

When were you divorced the second time?

Reason for second divorce?

When were you married the third time?

When were you divorced the third time?

Reason for third divorce?

If Widowed, When did your wife die?

What was the cause of death?

Are you subject to any alimony payments from any of the above marriages?

If yes, how much $?

If yes, is it per week month other

If currently married, does your wife work? Yes No

If yes, Where does your wife work?

If yes, what is your wife's occupation?

If yes, what is your wife's income?

D. CHILDREN

How many children do you have

None 1 2 3 4 5 +

If you have no children, please move to section E of the application.

Name of Child 1

Birthday of Child 1

Who is mother of Child 1

Name of Child 2

Birthday of Child 2

Who is the mother of Child 2

Name of Child 3

Birthday of Child 3

Who is the mother of Child 3

Name of Child 4

Birthday of Child 4

Who is the mother of Child 4

Do you owe child support?

If yes, do you owe child support per Yes No Other

If yes, how much child support do you owe?

Where are your children now?

E. EDUCATION

What is your highest level of education you have completed

Grade School Middle School High School Some College College Trade School Graduate School

If Grade School, Middle School or High School are the highest levels of education you have completed please skip to section F.

If you went to college, Where did you go?

If you went to college, what was your major/minor?

If you went to college, what year did you graduate?

If you went to trade school, what was the name of the school?

If you went to trade school, what was your degree in?

If you went to trade school, what year did you graduate?

If you went to grad school, what is your degree in?

F. OCCUPATIONAL EXPERIENCE

What is your usual occupation?

How many years have you been in this trade?

Are you working now?

If not working, why not?

How long have you been at your current job?

Is your current job your usual occupation?

If it is not your usual occupation, why not?

What was your last steady job? Where? and for how long were you there?

Please list any special skills you have:

Have you ever been fired from a job because of your alcohol or drug use?

If yes, please explain:

Have you ever quit a job because of your alcohol or drug use?

If yes, please explain:

Number of Jobs you have had in the past five years?

Preferred type of work:

G. MILITARY EXPERIENCE

Are you a veteran?

If you have no military experience/ are not a veteran please skip this section of the application.

Which Branch of Service did you serve?

Highest Rank:

How long were you in the service?

Date of Discharge

Type of Discharge

If you did not receive an honorable discharge please explain:

Serial Number

Are you retired from the Service?

Amount of Retirement Income?

Do you have a service related disability?

Amount of Disability Income?

Were you ever court - martialed?

If you were court - martialed please explain and give the results of the court martial:

H. MEDICAL INFORMATION

What is your current state of health?

How tall are you?

How much do you weigh?

Have you had any recent weight changes?

If yes, what is your usual weight?

Please List all major illnesses or operations you have had in the past:

Are you handicapped or disabled in anyway?

If yes, what is your type of handicap?

Do you NOW have a venereal disease?

Have you EVER had a venereal disease?

If yes, what do you / or did you have?

If yes, when did you have it?

If yes, when was it cured or arrested?

Have you ever been tested for HIV?

When were you tested for HIV?

Are you open to being tested for the HIV virus while a resident at Dunklin?

If you use any tobacco products are you willing to give it up to come into the program?

Have you ever been hospitalized for alcoholism or drug addiction?

If Yes, Please list Where, When, and why you were hospitalized?

Are you taking any medications prescribed or over the counter?

If yes, what prescription are you taking and how long have you been taking it?

If Married, does your wife take any prescribed or over the counter medications?

If your wife takes medicine, what does she take?

Have you ever suffered from depression?

If yes, please describe any treatment you have received or what has been done to help your depression?

Have you ever had any thoughts of suicide?

If yes, when have you had thoughts of suicide?

Have you ever attempted Suicide?

If yes, When? And how did you try to do this?

Have you ever been treated for psychiatric illness?

If yes, please explain and describe treatment, if any:

Would you be willing to sign a release of information from so that we might obtain information concerning social, medical or psychiatric reports or information?

I. ALCOHOL & DRUG USE HISTORY

What was your alcoholic beverage(s) of choice prior to being accepted for this interview?

Whiskey Liqour Beer Other None, drugs are my issue

How much would you drink?

How long (how many years) have you drank alcohol?

What drugs were you using prior to being accepted for this interview?

Weed Opiods: Heroin, Suboxen, dope, opium, etc... Stimulants : Cocaine, crack, meth, speed, etc... Club Drugs: Ecstasy, roofies, etc.. Hallucinogens Steroids Inhalants Other None, alcohol is my issue

How much were you using?

How long (how many years) have you been using drugs?

What was your age and the circumstances of your first drinking or drug use experience?

Has your drinking or drug use pattern changed?

If yes, In what ways has it changed?

What is your drinking or drug use pattern now?

Have you ever tried to control your drinking or drugging problem on your own?

If yes, How have you tried to do this?

Have you ever had

A blackout Seizure Hallucinations DT's None of the above

What is your drinking and/or drugging behavior?

Aggressive Calm Abusive Quiet Happy Angry Other

What is your longest period of sobriety in the past two years?

Have you ever misused or abused prescription drugs?

If yes, what drugs have you misused or abused?

Have you ever misused or abused over - the - counter drugs? (Nyquil, No-Doz, Vivarin, Aspirin, Etc)

If yes, what have you misused or abused?

Have you ever used or abused any other substances not listed above in the past to change your mood or get you high?

If yes, what have you used?

J. LEGAL AND ARREST RECORD

How many times have you been arrested?

What is the longest time you have spent in jail?

What misdemeanor(s) and/or felony(s) have you spent time in jail for?

Are you presently involved in any lawsuits?

Has your driver's license ever been suspended or revoked?

If yes, why and when was it suspended or revoked?

Have you ever been to prison?

If yes, When?

If yes, Where?

If yes, Why?

Are there any charges pending against you at this time?

If yes, please explain:

Do you have any court dates pending at this time?

If yes, when?

Do you have any objections to us notifying the law that you are here?

Are you presently on probation or community control?

If yes, for how long are you on probation or community control?

If yes, in what county are you on probation or community control?

If yes, what is your probation or community control officer's name?

If yes, what is your probation or community control officer's phone number?

K. RELIGIOUS BACKGROUND

Are you a member of a church?

If yes, what is the name of the church?

If yes, which denomination of church were you a member of?

If yes, what city / state is the church located in?

If yes, what is the pastor's name?

If yes, how often did you attend?

Have you ever been a member of a church?

Were you ever a church officer, sunday school teacher, or in church leadership?

If yes, what did you do?

When did you last attend church on a regular basis?

How often do you read the bible?

Do you ever pray?

If you pray, when do you pray?

Are you saved?

If yes, when were you saved?

If you are married, what is the religious background of your wife?

How did you hear about Dunklin?

Description

Please fill out this Regeneration Program Application form and when finished click submit.

Please know that some questions are required and the form will not be able to be submitted without them being filled out. You will need to make sure all required questions are answered before submitting.

The application must be filled out by the man seeking help.

Regeneration Program Application

Description

Please Fix the Following