application package instructions - clover...

Revised 10/31/13

PAGE 1 INSTRUCTIONS – 1 OF 2

Application Package Instructions

*Please Read All of the Following Instructions Carefully*

APPLICATION PACKAGE

Application Package Instructions . . . . . . . . . . . . . . . . . . . . . . . . . Pages 1 and 2

Checklist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Page 3

Program Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Page 4

Program Application . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Pages 5 through 16

Health Screening Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Pages 17 and 18

Pre-Existing Medical Condition Guidelines. . . . . . . . . . . . . . . . . 9

Dental & Medical Policy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Page 20

Statement of Student Rights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Page 21 and 22

Daily Program Schedule . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Page 23

1. Pay Application Fee: There is a one time non-refundable application fee of $50.00, that must be paid in

full before your application will be processed.

Payment Methods:

a. Money Order: Must be sent in with the completed Program Application Pages 5 through 16 of the

application package. Money Orders can be made out to: Teen Challenge of the Mid-South.

b. No Checks: No personal checks accepted for the application fee. Money Order Only!

c. Credit/Debit Cards: ou can pay your application fee safely through PayPal using a credit/debit card, or

PayPal account. You do not have to have a PayPal account to pay your application fee online. Visit our

website at: www.teen-challenge.com and click on the Admission/Cost Page.

* REMEMBER: Your application WILL NOT be processed Until the application fee is paid in full.

2. Read the Program Requirements Page 4 and KEEP for your own personal records.

3. Complete the Program Application. Only Pages 5 through 16 at this time

4. DO NOT fill out the Health Screening Form Pages 17, 18 Until you are instructed to do so!

5. Attach a copy of a recent photo to the front of your Program Application Page 5

Revised 10/31/13

PAGE 2 INSTRUCTIONS – 2 OF 2

6. Mail or Fax in your Program Application Pages 5 through 16 to us at:

Teen Challenge of the Mid-South Fax: (423) 265-7763

1108 W. 33rd Street

Chattanooga, TN 37410

* REMEMBER: If you are paying your application fee of $50.00 with a Money Order; mail it in with your

completed Program Application Pages 5 through 16 at this time. Otherwise, go online and pay it there.

7. Call either Joe or Sheila to schedule your first phone interview; do this after you have completed and

returned the Program Application Pages 5 through 16.

Male In-Take Counselor Female In-Take Counselor Joe Zinnert: (423) 756-5558 ext. 125 Sheila Thomas: (423) 756-5558 ext. 170

8. Read the Statement of Student Rights and Daily Program Schedule Pages 21, 22 & 23 and KEEP for your

own personal records.

9. Health Forms: After you have had your first phone interview with your In-Take Counselor; follow their

instructions regarding the Health Screening Form, and Pre-Existing Medical Condition Guidelines Pages

17, 18, 19 & 20 as well as any other instructions they may give you.

10. Pay Entry Fee: There is a one time non-refundable processing fee of $500.00, which must be paid prior

to coming into the program (or on the day of entry if prior approval has been granted). This should be done

as soon as your In-Take Counselor has informed you to do so.

Payment Methods:

a. Money Order: Money Orders can be made out to: Teen Challenge of the Mid-South.

b. No Checks: No personal checks accepted for the entry fee. Money Order Only!

c. Credit/Debit Cards: You can pay your application and processing fee safely through PayPal using a

credit/debit card, or PayPal account. You do not have to have a PayPal account to pay your fees online.

Visit our website at: www.teen-challenge.com and click on the Admission/Cost Page.

* REMEMBER: You WILL NOT be allowed to enter the program Until the processing fee is paid in

full.

11. Wait: Once you’ve finished the application process and all of the above steps have been completed, your

name will be put on our waiting list for the next available bed.

* PLEASE NOTE: Our goal at Teen Challenge of the Mid-South is to help make the application and induction

process as easy as possible. However, it is your responsibility as the applicant to remain in contact with your

In-Take Counselor to ensure a smooth transition into our residential program.

http://www.teen-challenge.com/

Revised 10/31/13

PAGE 3 APPLICATION PACKAGE CHECKLIST

Application Package Checklist

TEEN CHALLENGE OF THE MID-SOUTH, INC.

1108 W. 33rd STREET

CHATTANOOGA, TN 37410

Phone: (423) 756-5558 • Fax: (423) 265-7763

* Use this application checklist and stay on top of your application tasks, paperwork, and deadlines *

CHECKLIST: Make check marks on the line as you complete each STEP.

____ I have paid my $50.00 application fee online ____________ or mailed it on ____________

(Date) (Date)

____ I have read the Program Requirements Page 4

____ I have attached a copy of a recent photo to the front of the Program Application Page 5

____ I have completed the Application for Admission Pages 5 through 9

____ I have read, signed, dated and witnessed the Student Agreement Page 10

____ I have read, signed and dated the General Program Rules Agreement Pages 11 and 12

____ I have read, signed, dated and witnessed the Release of Information Form Pages 13 and 14

____ I have completed the Financial Responsibilities of Applicant/Families Page 15 & 16

REMEMBER: Do Not fill out your Health Screening Form Pages 17, 18, 19 & 20 until your In-Take

Counselor gives you instructions to do so!

____ I have mailed or faxed in my Program Application Pages 5 through 16 on ____________ (date)

____ I have called either Joe or Sheila and scheduled my first phone interview

____ I have read the Statement of Student Rights and Daily Program Schedule Pages 21, 22 & 23

____ I have had my first phone interview on ____________ (date)

____ I have followed my In-Take Counselor’s instructions regarding the Health Screening Form

and Pre-Existing Medical Condition Guidelines Pages 17, 18, 19 & 20 as well as all other

instructions they gave me.

____ My In-Take Counselor has issued me an entry date

____ I have paid my $500.00 processing fee online ____________ or mailed it on ____________

(date) (date)

Revised 10/31/13

PAGE 4 PROGRAM REQUIREMENTS

Program Requirements


1108 W. 33rd STREET


Phone: (423) 756-5558 • Fax: (423) 265-7763

*Please Read The Following*

Listed below are some of our program requirements:

• You must be at least 18 years of age or older (Cannot exceed the age of 50)

• You must have a substance abuse problem or a life controlling addiction

• Willing to consider a faith-based approach

• Willing to commit to a minimum of 12 months

• Willing to share a room with others, possibly of different races and backgrounds

• Willing to cut off all contact with non family members while in the program (This includes, but is not limited to any girlfriend or boyfriend that you may be involved with.)

* Note: We do not honor common-law marriages.

• Must have a Social Security Card and Photo ID

• Must resolve any legal matters before entering the program (This includes, but is not limited to any warrants for your arrest.)

• Must submit to random drug tests while in the program (This includes, but is not limited to nicotine testing since we are a non-smoking facility.)

• Must have a Health Examination and lab work done prior to entering the program (This would be your responsibility. We do not schedule, provide or pay for medical test.)

• We recommend a dental examination. If dental issues arise, you may be required to withdraw from the program.

• Must have a T.B. test done within 30 days prior to entering the program (This would be your responsibility. We do not schedule, provide or pay for T.B. tests.)

• We do not allow any psychiatric medications to be taken while in the program (This includes, but is not limited to prescription painkillers, anti-depressants, mood stabilizers, etc.)

* Note: Non-Psychiatric medications prescribed by a doctor for physiological reasons,

such as epilepsy, blood pressure, diabetes, etc. are allowed but will be

administered by staff while in the program.

• We do not allow women that are pregnant

• We do not allow those who are HIV positive

• We do not allow those who have been convicted of a sexual crime (We are located next to a school).

* If you meet the requirements above and the financial requirements (see Pages 15 & 16), please continue on to

the Program Application

Revised 10/31/13

PAGE 5 / PROGRAM APPLICATION APPLICATION FORM 100

Application for Admission

I. GENERAL TODAY’S DATE / /

1. Name:

First Middle Last

2. Present Address:

Street City State Zip

Phone:

3. Referred to Teen Challenge by:

Name Phone

Address City State Zip

Relationship (Friend, Relative, etc.)

II. PERSONAL

1. Birthdate: / / Age: Sex: M F Weight: Height:

2. Race: White Black Asian or Pacific Islander Hispanic American Indian Other

3. Are you an American Citizen? Yes No

4. Are you living on your own? Yes No

Reason for leaving home:

5. What kind of problems did you have while living at home?

6. Last grade completed: GED? Yes No

7. Have you served in any branch of the military? Yes No Which Branch?

Type of discharge:

8. Do you have any Reserve or military obligation at this time? Yes No

If yes, explain:

9. What is your sexual preference? Homosexual Bisexual Transsexual Heterosexual

10. Have you ever engaged in homosexual activities? Yes No How recently?

11. What are your present living conditions? With Whom? Where?

How are you supported?

12. What significant changes have occurred in your life recently? (Behavior, employment, activities, etc.)

13. What is your email address? What is your MySpace address?

What is your Facebook address?

Attach

Photo

Here

Revised 10/31/13


III. MARITAL STATUS

1. Single Married Separated Divorced Common Law Widowed Remarried

2. Spouse or Ex-Spouse’s Full Name: Phone:

Address City State Zip

3. If separated or divorced, please give date:

Reason for breakup:

What is the relationship like now?

4. Do you have a boyfriend/girlfriend/fiancé? Yes No

If yes, what is the relationship like?

5. Do you have dependents? Yes No

Dependent’s Name Birthdate Age Other Parent’s Name Child Support Custody

Me Other

IV. DRUG HISTORY

1. Have you ever experimented with drugs or alcohol? Yes No

2. Why did you experiment with or become involved with drugs?

Drugs used:

Usage How Often Used?

1st Time Last Time Once Several Often Regularly

Alcohol

Barbiturates (downers)

Amphetamines (uppers)

Heroin

Cocaine

Hallucinogenics

Opium

Glue

Tobacco

Marijuana

Other (Specify)

3. Do you consider yourself addicted? Yes No

Explain:

4. I depend on drugs (Check which one(s) apply to you) To cope with life To be “in” with crowd

For pleasure To escape reality Other

5. Longest period clean? When was that?

Revised 10/31/13


V. LEGAL STATUS

1. Have you ever been arrested? Yes No How many times?

Date Charges

Convicted?

(Yes or No) Sentence Time Served

2. Are there pending charges? Yes No If yes, when is court date?

3. Have you ever been on probation? Yes No Are you now on probation? Yes No

How long have you been on probation? Time remaining?

How do you report? In person By Mail How often do you report?

Name of Probation Officer: Phone:

Address:

Are you on parole? Yes No

How do you report? In person By Mail How often do you report?

Name of Parole Officer: Phone:

Address:

4. Have you ever been in prison? Yes No When? Where?

5. Name of Lawyer: Phone:

Address:

VI. SPIRITUAL STATUS

1. Do you believe in God? Yes No Uncertain

2. Have you ever committed your life to God? Yes No

If so, Where? Date:

a. What were the circumstances that led to your decision?

b. How many times have you turned from God?

3. How often do you attend church? Never Sometimes Regularly

Denominational preference:

4. Are you a member of any church or religion? Yes No

If yes, which one?

5. What recent changes have you had in your religious life (if any)?

6. Have you ever been involved in the occult? Yes No

7. Explain your need of God, what your standing with Him is now (ie: good or bad relationship, no relationship at all, etc)

Revised 10/31/13


VII. FINANCIAL STATUS

1. Are you receiving welfare, unemployment compensation, disability payments, workman’s compensation, alimony, or

other income? Yes No

Explain:

2. Do you have any outstanding debts or fines? Yes No

Explain:

Owed to Amount Address Phone Payments

VIII. THE PRESENTING PROBLEM

1. What is the main problem in your life, as you see it? (Why are you wanting to come here?)

2. What have you done about it?

3. What are your greatest needs, in order of priority?

4. Have you ever been involved in a Teen Challenge program before? Yes No Can’t Remember

If yes, When? Where?

5. Have you ever been in any other type of program before? Yes No How many?

Religious Non-Religious

Program Name Dates City & State Reason for Leaving

6. Why do you wish to be admitted to Teen Challenge of Chattanooga?

7. What are you expecting (believing) God to do in your life while you are at TC?

8. Are you expecting God to do it all (“zap” you) or do you believe it will take commitment and sacrifice on your part?

Describe what you’re willing to do, or what you think is required of you?

Revised 10/31/13


IX. HEALTH STATUS

1. Range your general health: Excellent Good Fair Poor

2. Do you have any communicable diseases? Yes No If so, what?

Do you have epilepsy, seizures, diabetes? Yes No If so, what?

3. List any medical problems or handicaps:

4. Are you presently receiving medical care? Yes No If so, where?

5. Are you currently taking medication? Yes No If so, please list:

6. Do you have any physical problems due to drugs/alcohol? Yes No

7. Have you been hospitalized within the past 12 months? Yes No If so, please explain:

8. List all medications to which you are allergic or sensitive:

9. List all allergies (including food, latex, insects, etc.)

10. Have you ever had psychiatric care? Yes No If so, please explain:

11. Have you ever attempted suicide? Yes No If so, How?

Was it drug or alcohol related? Yes No If so, explain:

12. What is the condition of your teeth?

(Must provide a copy of dental exam and must have all the necessary dental work completed before coming into Teen

Challenge; otherwise must wait until Reentry and you will be responsible for all expenses incurred. Unless something

arises of an emergency nature, you will not be taken to a dentist while in Teen Challenge.)

For Women Only:

1. Are you pregnant? Yes No Maybe Why do you think so?

2. Menopause? (Change of Life) Yes No If so, when?

3. Have you ever had an abortion? Yes No If so, how many times?

Please explain the circumstances of each time:

Revised 10/31/13

PAGE 10 / PROGRAM APPLICATION STUDENT AGREEMENT

Student Agreement

1. I have read the general program rules and consent to abide by all of them, whether I agree with them or not.

2. I will dedicate myself to the discipleship program until it is recognized by the TC staff that I qualify for

completion. I realize this is only possible by submitting to the Lordship of Jesus Christ and that I cannot do this

in my own strength.

3. I release to Teen Challenge the right to search, read, and withhold my mail in the manner explained in the rules.

4. I release the right to Teen Challenge to do a room search and/or drug screen without warning. (Note: This is not

done routinely, but only at times of definite cause.)

5. I release the right to Teen Challenge to make a thorough search of my person and belongings on the day of my

admission.

6. I understand that withdrawal from drugs, alcohol, and cigarettes will be done "cold turkey" aided only by prayer.

If this is not agreeable, withdrawal should be done prior to entrance.

7. I understand that Teen Challenge will not be held responsible for any of my personal property left, lost, or stolen

while I am in the Teen Challenge program. When leaving Teen Challenge, I understand that all my personal

property must be taken with me.

8. I release Teen Challenge from all financial or legal responsibilities in case of accident, injury, illness, or other

misfortune.

9. I understand that I will not receive payment for the work I do while in the Teen Challenge program. I also

understand that the purpose of this work is to aid in my character development.

10. I release the right to Teen Challenge to withhold any of my belongings that they deem necessary. Any items not

specifically listed under "Forbidden Items" in the rules will be held for me until my departure.

11. I understand that upon arrival I must deposit with Teen Challenge the cost of a return bus ticket to be held for me

in case I am dismissed or decide to leave the Teen Challenge program prematurely.

12. I agree to submit to the authority of all staff members.

Date

Applicant's Signature

Revised 10/31/13

PAGE 11 / PROGRAM APPLICATION PROGRAM RULES AGREEMENT 1 OF 2 – FORM 101

General Program Rules Agreement

The following are just some of the basic rules of Teen Challenge of the Mid-South. You will be

provided with a complete list of rules upon admittance.

Christian Growth Center:

1. I understand that Teen Challenge is a Christian Growth Center and I agree to be subject to Biblical

teaching and Christian forms of behavior.

2. I agree to assume personal responsibility for my own attitude and behavior at all times. I understand

that what program authority calls incorrect behavior and a bad attitude will be confronted and may be

disciplined if necessary. I will agree to do the disciplinary action or project with an improved attitude.

3. I understand that my main purpose for being in the program is to learn a new way of life, not just to get

off drugs.

Personal:

1. I will not possess or use drugs at any time, including psychiatric medication.

2. I will not use tobacco in any form or have cigarettes in my possession.

3. I will not curse or use off-color expressions or bodily gestures.

4. I will not talk about street life, drugs, or reminisce about past wrong doings.

5. I will not horseplay or engage in any other inappropriate body contact.

6. I will not become part of a clique.

7. I will not call other people names.

8. I will not go outside of the house without staff permission.

9. I will not bring a radio, tape recorder, musical instrument, books, knives, lighters, etc.

10. I will not grow a beard (men) while in the program.

11. I will not sing, whistle, or hum secular songs while in the program.

Family:

1. I will agree to the staff screening and perhaps reading my mail.

2. I agree to write only members of my immediate family - no letter writing to girl/boy friends.

3. I agree to make (or receive) only two phone calls per week, after a 14-day waiting period.

4. I agree not to have any visits from my immediate family until after 30 days.

Revised 10/31/13

PAGE 12 / PROGRAM APPLICATION PROGRAM RULES AGREEMENT 2 OF 2 – FORM 101

Group:

1. I agree to participate in all scheduled activities including class, chapel, church, work, and recreation. I

will do what I'm required to do in each of these activities.

2. I agree to conduct myself in a Christ-like manner and will not do anything in public that will call

attention to myself or reflect badly upon the whole group.

3. I understand the length of the Teen Challenge Program is a minimum of 12 months. I agree to commit to

complete the entire Teen Challenge Program.

Discipline:

1. I understand that I'm expected to be prepared, in place, and on time for all my scheduled activities 24

hours a day. I also understand that any tardiness, unpreparedness, and other forms of carelessness will

result in disciplinary action.

2. I understand that my room must be kept in a neat and orderly manner at all times. I agree to work

together with my roommates to keep it clean and in shape for inspection.

3. I understand there will be a dress code.

4. I understand there will be a grooming code: shave before breakfast (men), hair combed (also before

breakfast and throughout the day), shower once a day, etc.

5. I understand that disciplinary action may include: extra duty, loss of privileges, suspension, or dismissal.

I have read these Rules and my signature indicates that I have a good understanding of them and that I'm

willing to commit myself to these agreements and to the more detailed Handbook agreements I will receive

upon Intake.

Staff Signature _________________________ Student Signature ________________________

Date: __________________

STUDENTS WITH WIFE AND/OR CHILD/CHILDREN:

The needs of my wife and/or children are being provided while I’m in Teen Challenge.

Staff Signature _________________________ Student Signature ________________________

Date: __________________

Revised 10/31/13

PAGE 13 / PROGRAM APPLICATION RELEASE OF INFORMATION / INSTRUCTIONS

Release of Information Instructions VERY IMPORTANT: This release of Information document informs us of any person that you want informed

of your intent to enter the program, or who may be involved in your intake process. The information exchanged

with these people may be utilized to determine your eligibility for the program, and develop or revise a

treatment plan once enrolled. Because of Federal confidentiality laws, you must list, EVERY person, even

immediate family members, that are to be informed of your intent or may be involved in the intake process. In

short, if a person’s name is not on the list, we will not be allowed to communicate with them or even

acknowledge the receipt of an application, regardless of who they are or their relationship to you. The

ONLY exception to this will be in accordance with Federal guidelines.

EMERGENCY NOTIFICATION

Next of Kin

Name: _____________________________________________ Relationship: _____________________

Address: _____________________________________________

_____________________________________________

Phone: _____________________________________________

Fax: _____________________________________________

Email: _____________________________________________

Signature of Applicant ________________________________________ Date ______________

● Please turn page over and print your full name on the top line.

● List the names of those you want involved or notified as well as their title, relationship and phone/fax

number.

● You and a witness sign and date the form.

Revised 10/31/13

PAGE 14 / PROGRAM APPLICATION RELEASE OF INFORMATION FORM

Release of Information Form

I, do hereby give Teen Challenge of the Mid-South Inc. and the following

people and entities:

Name of Probation Officer (please print)

Name of Attorney (please print)

1. /

Name (please print) Title, Relationship, Phone/Fax Number

2. /


3. /


4. /


5. /


6. /


Permission to share and communicate personal information concerning me for the purposes of determining

eligibility for and or facilitating entry into the Teen Challenge residential program located in Chattanooga,

Tennessee. This release shall also extend to the development and revision of my treatment plan while enrolled

in the program as well as making the transition back to normal life after the program.

Student Signature _________________________________ Date ______________

Witness Signature _________________________________ Date ______________

*This consent is subject to revocation in writing by the student at any time except to the extent that the ministry

or person who is to make the disclosure has already acted on it.

This consent automatically expires one year and six months from the date it is signed.

Revised 10/31/13

PAGE 15 / PROGRAM APPLICATION FINANCIAL FORM – 130.1

Financial Responsibilities of Applicant/Student

1. Physical examination, including blood tests, before entrance into Teen Challenge of the Mid-South Program, hereafter

referred to as Teen Challenge for the purpose of this document. (Required)

2. Return fare (cash) for return home from Teen Challenge provided upon entrance into the Program. (Required)

3. Provide student account money: Cash or money order ONLY, Cannot exceed $30.00. Money orders are to be made

payable to the student and are Non Refundable. (Required)

4. Accept responsibility for payment of any of the following (if they are necessary). (Required)

* Medical bills and dental bills

* Eye examinations, glasses, clothing and shoes

* Psychological testing with professional consultant, if indicated

5. The cost for a secular rehabilitation program exceeds $10,000 for a 28-day program. Many are even higher. The cost

to care for a student in the Teen Challenge of the Mid-South program is approximately $3,000.00 per month.

Due to the extended recession and the loss of donation income (foundations, church, corporate and individual), we have

had to make a very difficult decision. We must now require the family to partner with us to provide support for the

loved one they are helping gain entrance into our program.

As stated in the above policy, we (Teen Challenge) will do our part to raise 90% of the cost to care for the student. We

are asking the family to commit to the remaining 10% of the cost as a “minimum” support level. This can be done by

using the same methods that we use, contacting family, friends and your church family to give towards this support.

While we do receive food stamp subsidies for some (not all) students, it in no way covers the cost to feed our residents

for a month.

After the application is received, the $50.00 (non-refundable) application fee and the initial $500.00 processing fee

(non-refundable) paid, the family will be required to raise/donate a minimum level of support of $300.00 per month.

This is a joint effort between our ministry and your family network to see a life changed. We can no longer provide the

program to those who feel no need to be a part of the process. We believe that you feel as we do, your loved one’s life

is worth your investment. The process will work like this:

A. $50.00 application fee (paid when application is submitted)

B. $500.00 non-refundable processing fee paid prior to entrance into the program

C. MINIMUM monthly support level of $300.00 per month

A Credit or Debit card is required to be registered on file with the finance department before the assigned entry date. Tuition charges will be deducted from the account on the 1st of each month. If you prefer to pay by check or

money order, a credit card will still be required to be registered but will not be charged if the check arrives by the 1st of

the month.

If the applicant receives SSI (Social Security) or other Government benefits (disability, pension, etc.), the Social

Security Administration has designated that 30% of your benefit must be applied to room and board. While enrolled in

the program, you will be required to pay 30% to Teen Challenge for your housing. This amount can be applied to the

monthly fee. Automatic bank payment is preferred.

Revised 10/31/13

PAGE 16 / PROGRAM APPLICATION FINANCIAL FORM – 130.1

6. Accepting my Biblical responsibility (I Timothy 5:8), I commit to provide $ _____________________ monthly while

_________________________________________ (student) is in the program.

Student Name (Please Print)

Sponsor Name (Please Print)

Telephone #

Address

Date

City State Zip

Student Signature Telephone #

Email Address Sponsor Signature

Credit Card Information:

( ) Visa ( ) Master Card ( ) Discover ( )Am. Express

Credit Card Number: - - -

Expiration Date:

Print Name as it appears on the card:

Billing Address:

Card holder Phone:

Card holder Signature:

NOTE:

Failure of the family to follow through on their part of the agreement will result in the release of the student from the

program. As we promise to keep our part of the agreement, the family needs to do the same. Failure to do so would

constitute a breach of the agreement.

Revised 10/31/13

PAGE 17 HEALTH SCREENING FORM 1 OF 2 / FORM – 402

Health Screening Form


1108 W. 33rd STREET


Phone: (423) 756-5558 • Fax: (423) 265-7763

* To Be Completed By Physician, Physicians Assistant or Nurse Practitioner ONLY! *

Today's Date: ________________

1. Name _______________________________________ D.O.B.________________________

2. Present Illness/Complaint/Disabilities, if any: _______________________________________

___________________________________________________________________________

3. Allergies: ___________________________________________________________________

4. Medicine currently prescribed and reason: _________________________________________

__________________________________________________________________________

5. Has client been exposed to any communicable diseases: Yes _____ No _____

If yes, please specify: _________________________________________________________

6. History of chronic or major illness: _______________________________________________

__________________________________________________________________________

7. Operations: ________________________________________________________________

__________________________________________________________________________

8. Hospitalizations: _____________________________________________________________

__________________________________________________________________________

9. Immunizations: Last Tetanus Toxoid _______ Polio _______ Measles ______ Mumps_____

Rubella _______ Other _______________________________________________________ Physical Examination

Code: Satisfactory = S Unsatisfactory = U Not Examined = O

Height _______ Weight _______ B/P _______

Pulse _______ Respirations _______ Temperature _______

Revised 10/31/13

PAGE 18 HEALTH SCREENING FORM 2 OF 2 / FORM – 402

Patient Name _______________________________ Date ___________________

General Appearance (including schemata of drug abuse)

Nutrition _________________________________________________________________________

Head: ___________________________________________________________________________

Ears ___________________________ Hearing: R _______ L _______

Eyes ___________________________ Vision: (without glasses) R _______ L _______

(with glasses) R _______ L _______

Nose _______ Throat _______ Mouth/Teeth _______ Neck/Thyroid _______

Chest _______ Cardiac _______ Abdomen _______ Genitalia _______

Hernia _______ Skin _______ Musculo Skeletal _______ Neurologic _______

Required Lab Tests (for Male & Female) *Attach computer printout of all test results*

STD TESTS: Syphilis _____ Gonorrhea _____ Chlamydia _____

HEPATITIS PANEL: A _____ B _____ C _____

Hep B surface antibody _____

Hep B core antibody IGM _____

If you test positive for Hep B or C you must have a liver function test and a Doctor’s clearance letter.

Urinalysis _____

H.I.V. _____

Pregnancy _____ (female only)

TB _____ This test must be done within 30 days prior to entering program

General comments, assessments, and recommendations on above:

________________________________________________________________________________

____________________________________________________________________________

_______________________________________ Signature of Examining Physician

Address: ______________________________ City: _________________________

State: ________ Zip: __________________ Phone: __________________________

Revised 10/31/13

PAGE 19 PRE-EXISTING MEDICAL CONDITION GUIDELINES – 402.2

Pre-Existing Medical Condition Guidelines


1108 W. 33rd STREET


Phone: (423) 756-5558 • Fax: (423) 265-7763

Guidelines for applicants who have any serious medical condition are as follows.

We strongly suggest you present this form to your Physician:

1. You must provide us with a statement from your physician that you are asymptomatic or stable and don’t require ongoing “outside” medical treatment for this condition. We must have this prior to setting an initial entry date. 2. The condition must be able to be controlled with simple measures that can be implemented within the confines and structure of our current program. 3. You, the student, must take full responsibility for the daily requirements of your condition without reminders from staff i.e. (checking blood sugar levels, following a proper diet, taking medications as instructed etc.) 4. If symptoms manifest, need for treatment arises, or your condition becomes uncontrollable while enrolled, you will be required to withdraw from the program. This applies to any ongoing/serious medical condition. 5. Once your condition has been brought under control to our original requirements, you MAY be given the opportunity to re-apply for the program.

6. If you take a medical leave, you will be required to continue paying your full tuition in order for your bed to be held. If you do not return to the program, your tuition fee is NOT refunded.

7. All Tuition fees are non-refundable. Signature _________________________________________________ Date ___________________________

Revised 10/31/13

PAGE 20 DENTAL

Teen Challenge of the Mid-South

Dental/Medical/Drug Withdrawal Policy

Due to the fact that Teen Challenge of the Mid-South, Inc. is NOT a medical facility, the following

policies have been enacted:

DENTAL:

It is STRONGLY ADVISED that students get a dental check-up prior to entering the program! Students

enrolled in our program WILL NOT have access to a dentist for 8-9 months except for emergencies or while on

pass. In the event of an emergency, the student’s family will be responsible for any medical costs (see Financial

Responsibilities, page 15). If a student in the program requires on-going dental treatment that cannot be taken

care of while on pass, they will be required to take a leave of absence. Once the work is completed and we

receive verification, they can return to the program.

Date of last dental check-up ________________ Applicant Initial_________

MEDICAL:

Students will only have access to medical care in case of emergencies. Students that have a pre-existing condition or a

condition that develops while enrolled in the program which requires on-going medical treatment will be required to take

a leave of absence (see pre-existing guidelines on page 19 of the application). Applicant Initial__________

DRUG/ALCOHOL WITHDRAWAL:

Due to the fact that some withdrawal symptoms are unpleasant but some can be FATAL, severe alcoholics and those

taking certain medications require a physician’s statement that you have gone through a “de-tox” process or that you have

been weaned off the medication under their supervision. If you enter the program but are not able to participate due to

drug or alcohol withdrawal for more than 1-2 days, you will be required to take a leave of absence and go through a

medically supervised de-tox. To return to the program you would need to provide us with medical verification that you

have done so. Applicant Initial__________

I have read and understand the above policies.

Applicant Name (print):__________________________________________

Applicant Signature:__________________________________________ DATE:______________

Revised 10/31/13

PAGE 21 DENTAL

Statement of Student Rights


1108 W. 33rd STREET


Phone: (423) 756-5558 • Fax: (423) 265-7763

1. You will be fully informed upon admission of your rights and responsibilities and limitations of those rights imposed by the agreements of Teen Challenge of the Mid-South, Inc.

2. You may voice grievances to your counselor, staff, to the Vice President of Programs and President of Teen Challenge of the Mid-South, Inc., and to outside representatives of your choice with freedom from restraint, interference, coercion, discrimination or reprisal.

3. You will be treated with consideration, respect, and full recognition of your dignity and individuality.

4. You will be protected by your leaders at Teen Challenge of the Mid-South, Inc. from neglect from physical, verbal and emotional abuse (including corporal punishment) and from all forms of exploitation.

5. Teen Challenge of the Mid-South, Inc. will assist you in the exercise of your civil rights.

6. You will not be expected to perform services which are ordinarily performed by the staff of Teen Challenge of the Mid-South, Inc.

7. Upon admission you will be allowed to fill out a mailing list of those people to whom you desire to communicate, subject to approval by the Vice President of Programs. Mail will be opened in the administration office and given to the counselor for delivery to the student. Packages received will be opened in the presence of the staff. However, any mail or other communication which is not delivered to the student for whom it is intended shall be returned to the sender.

8. You will participate in the development of the treatment plan for your growth while here at Teen Challenge of the Mid-South, Inc. You will also receive sufficient information about proposed and alternative interventions and program goals.

9. You will participate in all scheduled activities including class, chapel, church, work and recreation.

10. You will have free use of designated areas in the facility. Consideration will be given regarding privacy, personal possessions and the rights of others.

11. You will be provided privacy and freedom for the use of the bathrooms.

12. Your personal items are subject to approval by the guidelines of Teen Challenge of the Mid-South, Inc.

13. You will be allowed visits at designated times and places under supervision.

14. Should you feel the need of outside assistance, you have the right to call the appropriate advocacy representative. Some are listed below:

Health Department American Civil Liberties Union Hamilton County Sheriff's Department

* See Title VI of the 1964 Civil Rights Act on the following page.

Revised 10/31/13

PAGE 22 STUDENTS RIGHTS 2 0F 2 / FORM– 164.1

Title VI of the 1964 Civil Rights Act

“No person in the United States shall on the basis of race, color or national origin, be excluded

from participation in, be denied benefits of, or be subjected to discrimination under any

program or activity receiving Federal financial assistance.”

Prohibited Practices

Denying any individual services, opportunities, or other benefits for which that individual is otherwise

qualified;

Providing any service or benefit in a different manner from that which is provided to others in a program

because of race, color, or national origin;

Segregating service recipients solely because of race, color, or national origin;

Restricting access to program services or benefits because of race, color, or national origin;

Adopting methods of administration which would limit participation by any group of recipients or

subject them to discrimination;

Addressing an individual in a manner that denotes inferiority because of race, color, or national origin;

Revised 10/31/13

PAGE 23 PROGRAM SCHEDULE

Daily Program Schedule


1108 W. 33rd STREET


Phone: (423) 756-5558 • Fax: (423) 265-7763

MONDAY - FRIDAY

5:50 AM

Early Wake-up (Optional)

6:30 AM

Wake-up/Clean Room

7:00 AM

Breakfast

7:30 AM - 7:50 AM

Morning Chores

8:00 AM - 8:50 AM (Mon, Wed, Fri)

Morning Prayer

8:00 AM - 8:55 AM (Tue, Thur)

Chapel

9:00 AM - 10:25 AM

Personal & Group studies

10:30 AM - 11:50 AM

Personal & Group studies

12:00 PM

Lunch

1:00 PM

Free Time

1:35 PM - 5:00 PM

Work Detail/

Outreach Opportunities

5:30 PM

Dinner

7:30 PM - 8:30 PM

Study Hall

8:30 PM - 9:45 PM

Free Time

9:45 PM

Prepare for bed and Devotions

10:00 PM

Devotions at desk or in bed

10:30 PM

Lights Out

SATURDAY

8:00 AM

Wake-up/Clean Room

8:15 AM

Breakfast

9:15 AM

Weekly House Cleaning/Chores

10:15 AM

Free Time

12:30 PM

Lunch

2:00 PM – 5:00 PM

Recreation

5:30 PM

Dinner

9:00 PM

Prepare for Bed and Devotions

9:30 PM

Lights Out

10:30 PM

Night Lights Out

SUNDAY

7:00 AM

Wake-up/Clean Room

7:30 AM

Breakfast

8:00 AM

May watch staff selected TV

9:00 AM

Church

1:30 PM

Lunch

2:00 PM

Free Time

2:00 PM - 5:00 PM

Visitation(2nd & 4rd Sundays)

5:30 PM

Church

After Church

Dinner

9:45 PM

Prepare for Bed and Devotions

10:00 PM

Devotions at desk or in bed

10:30 PM

Lights Out

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