For
Office
Use
Only
Date
Received
Doctor’s
Le0er
Received Interview
Date Date
of
Entry
RESIDENT APPLICATION FORM
1. Contact Details
▾ APPLICANT ▾ ADDITIONAL CONTACT PERSON
Name: Name:
Address:
Address:
Postcode:
Postcode:
Contact Telephone No.
Contact Telephone No.
E-mail address:
E-mail address:
Relationship to applicant:
Date Of Birth: D D M M Y Y
National Insurance No.
2. Family & Living Circumstances of Applicant
2.1 Marital Status: Single Married Separated Divorced Widowed
2.2 Number of children: Age(s)
2.3 Accommodation: Single Spouse Parents Friends Other
2.4 Do you own your own house? Yes No
2.5 Are you a council tenant? Yes No 2.6 Are you a private tenant? Yes No
2.7 Are you currently employed? Yes No
If yes, name of employer:
2.8 Are you currently on benefits? Yes No
If yes, details:
3. Accommodation
3.1 Have you ever lived in a supported housing environment? Yes No
3.2 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
If yes, give details:
3.3 Have you ever committed acts of physical violence against staff or other
residents in a place where you were living?
Yes No
If yes, give details:
3.4 Where have you lived over the past 2 years?
3.5 Who has provided support for you over the last two years?
(professional, workers, voluntary groups, religious groups, family members)
4. Health
4.1 Height: 4.2 Weight:
4.3 How would you describe your present health? Excellent Good Fair Poor
4.4 Do you have any physical impairment, chronic disease or disability? Yes No
If yes, give details:
4.5 Do you require assistance with daily activities as a result of any impairment? Yes No
If yes, give details:
4.6 Name of GP or last Doctor seen
Name: Telephone:
Address:
4.7 Prescribed medication:
1. 2. 3.
4. 5. 6.
5. Substance Misuse
5.1 Do you use alcohol? Yes No
5.2 Do you use drugs? Yes No If yes, do you inject? Yes No
5.3 What is your primary substance?
5.4 Do you require a medical detox? Yes No
5.5 About your usage:
Type
of
Substance Dosage Frequency How
long
have
you
ben
using
this
substance?
Alcohol
Heroin
Methadone
Subutex
Amphetamines
Cocaine/Crack
Ecstasy
Diazepam
Canabis
Legal
highs
Other(s)
5.6 Are any of the above prescribed to you? Yes No
If yes, which ones?
Name of prescriber:
Address:
Postcode:
Email:
Phone Number:
5.7 Have you been a resident of a Teen Challenge centre before? Yes No
If yes, where?
5.8 Are you currently supported by a drug/alcohol agency? Yes No
If yes, give details:
6. Mental / Emotional Health
6.1 Have you ever experienced mental or emotional health problems? Yes No
6.2 Have you ever seen a psychiatrist? Yes No
6.3 Are you currently under psychiatric care? Yes No
If yes, please give details of your Community Psychiatric Nurse / Psychiatrist:
Name:
Address:
Email:
Phone Number:
6.4 Have you ever been in hospital as a result of mental or emotional health problems?
Yes No
If yes, give details:
6.5 Are you prescribed any medication for mental or emotional health issues?
Yes No
If yes, give details:
Medicine Dosage Frequency When
did
you
start?
1.
2.
3.
4.
6.6 Have you ever had an eating disorder and/or have been known to self harm?
Yes No
If yes, give details:
7. Past Offences
7.1 Do you have a criminal record? Yes No
If yes, give details:
7.2 Have you spent any time in prison? Yes No
If yes, when & how long:
7.3 Do you have any outstanding warrants? Yes No
If yes, give details:
7.4 Do you have any outstanding court appearances? Yes No
If yes, give details:
7.5 Have you ever been prosecuted for any violent offences? Yes No
If yes, give details:
7.6 Have you ever been prosecuted for any sexual offences? Yes No
If yes, give details:
7.7 Have you ever been prosecuted for arson? Yes No
If yes, give details:
7.8 Are you subject to any statutory supervision or probation? Yes No
If yes, give details:
Name:
Address:
Phone Number:
8. Personal Statement
8.1 Please write in your own words why you want to come to Teen Challenge.
9. References
Please provide the details of two references (e.g. Doctor, Drugs Worker,Church Worker, Minister or Social Worker)
who has known you for the past six months.
9.1 Reference 1
Name: Profession:
Address:
Phone Number:
Email:
9.2 Reference 2
Name: Profession:
Address:
Phone Number:
Email:
10. Consent & Declaration
In order to make a decision about your admission to Teen Challenge it may be necessary to contact workers or
agencies that have been involved with you. We will only contact people with your permission and any information
received will be treated as confidential.
It should be remembered, however, that to process your application you must complete all the information
requested on this form. Your application might be held up if we are unable to liaise with other workers. To
complete your application it may be necessary to share information given during your assessment with other
relevant services.
I, , D.O.B D D M M Y Y
Of (present address)
give Teen Challenge permission to act on my behalf regarding my benefits and acquire any
information concerning my history from my doctor throughout the duration of my programme.
I also give my consent for the staff from Teen Challenge to obtain written and/or verbal
information about me from the following people for the purpose of assisting in my assessment
with Teen Challenge:
GP Probation Officer Psychiatrist/CPN Social Worker Drugs Worker
I have completed this application form truthfully and to the best of my knowledge.
I understand that any misleading information could jeopardise my entrance into the
programme or my remaining on it.
Signed: Date:
If you are completing this form electronically please note you will need to print off the consent & declaration page
and the health Information Sheet and send it by post to Teen Challenge.
Please send the completed form to:
Hope House
6 Church Road
Gorslas
Carmarthenshire
SA14 7NF
Fax: 01269 833168
or email: hopehouse@[Link]
For more information contact Teen Challenge UK on 01664 822221, email info@[Link]
or visit our website: [Link] Teen Challenge UK is a registered Charity.
Charity, No. in England & Wales 298900, in Scotland SC039475. A Member Country of Global Teen Challenge
Health Information Sheet
Please Print this page and take it to your G.P. to be completed, then return this page along with your application
form to Teen Challenge UK. You can send us your application by email, fax or post.
To be completed by your G.P.
Patient Name: Date Of Birth: D D M M Y Y
To your knowledge has this patient detoxed before? Yes No
If yes, could you
give details:
Are you currently prescribing this patient any medication? Yes No
If yes,what medication,
dosage and frequency:
Has this patient had any mental health problems? Yes No
If yes, could you
give details:
Is this patient being prescribed any anti-psychotic medication? Yes No
If yes, could you
give details:
Is there any medical reasons known to you why this patient should not
participate in a drug detoxification and rehabilitation programme? Yes No
If yes, what would that
reason be:
Doctors Signature: Date:
Please send the completed form to: Doctors
Hope House Stamp:
6 Church Road
Gorslas
Carmarthenshire
SA14 7NF
Fax: 01269 833168
or email: hopehouse@[Link]
For more information contact Teen Challenge UK on 01664 822221, email info@[Link]
or visit our website: [Link] Teen Challenge UK is a registered Charity.
Charity, No. in England & Wales 298900, in Scotland SC039475. A Member Country of Global Teen Challenge
