Application

NOTE: Before filling our the application please read our Application Handbook.

Admissions Application

*First Name
Middle Name
*Last Name
*Sex
*DOB (mm/dd/yyyy)
*Age
*SSN
*Current Address
*City
*State
*Zip Code
Country
Email 
*Phone
*Citizenship
If US - State of Residency
If Other Country - List Country
Marital Status



Race





Do you read at a 5th grade level or above?
Do you have a high school diploma?
GED?
Do you have any relatives or friends currently in our program?
Have you previously been in our program?
If yes, year?
I mainly need help with
If other, explain?
Do you use tobacco?
Have you ever been treated for chemical addiction?

If yes, list prior treatment facilities:
Name of Facility
Address
City
*State
Dates of treatment (mm/dd/yyyy): to
Reason for treatment
Did you complete the program?


Name of Facility
Address
City
*State
Dates of treatment (mm/dd/yyyy): to
Reason for treatment
Did you complete the program?


How did you hear about our program?
if Other, please list
In your own words, tell us why you want to come to New LIfe For Youth and the main issues you need to deal with while in the program:


Physical Health

Medical History (check all that apply to your current and past conditions)















Please list any current medical concerns you may have:
Are you currently being treated by a doctor?
Name of Primary Doctor
Address
City
*State
Phone
Fax
Dates of treatment (mm/dd/yyyy): to
Reason for treatment
Are you pregnant?
If Yes, Due Date
Please list all medications you are allergic to:
If being treated with prescribed narcotics please list all below:

IMPORTANT: Apllicants on prescribed narcotics will need to complete the regimen prior to admission or switch to non-narcotic pain medications.
Please list all current NON-Psychiatric medications:
Medication Reason Dosage


Special Needs

(please explain if checked yes)
Do you have any type of disability?
Explain
Do you have any chronic conditions?
Explain
Do you have any medical restrictions?
Explain
Do you have any type of special needs?
Explain
Do you have any allergies?
Explain
Do you require a special diet?
Explain


Dental/Vision Health

Do you have any dental issues that need treatment?
If yes, please explain
Do you wear glasses or contacts?
Do you have your glasses or replacement contacts?


Mental Health

Have you ever been treated for mental disorders?
if yes, when?
Have you ever been treated by a psychiatrist/psycologist?
If yes, please list last visit. (mm/dd/yyyy)
Mental Health History (check all that apply to your current and past conditions)





















Have you thought about or attempted suicide in the past 6 months?
If yes, when? (mm/dd/yyyy)
Name of Primary Psychiatrist/Psychologist
Address
City
*State
Phone
Fax
Dates of treatment (mm/dd/yyyy): to
Reason for treatment
Please tell us of any current mental/emotional health concerns you may have:


Financial Information

Are you presently employed?
If yes, what is your monthly income?
Do you receive any other income (SSI, disability, etc)?
If yes, what is the monthly amount?
Do you currently receive government assistance?
If yes, what type?


Legal Issues

Are you currently on probation?
If yes, list state/county?
Are you currently on parole?
If yes, list state/county?
Do you currently have court cases pending?
If yes, list state/county?
If yes, please list any pending charges and court dates:
Are you currently under investigation?
If yes, list state/county?
Do you have any outstanding warrants?
If yes, list state/county?
Have you ever been convicted of a violent crime?
If yes, please list each conviction and date.
Are you currently facing charges for a violent or sex-related crime?
If yes, please describe the charge(s) fullly.
Are you required to register as a sexual or predatory offender?
Probation Officer's Name
Address
City
*State
Phone
Fax
Attorney's Name
Address
City
*State
Phone
Fax
Legal History (check all that you have been involved with)






































If other, please list.


Emergency Contact

Name
Address
City
*State
Phone
Cell Phone


Program Fee Information

New Life For Youth average monthly cost per student is $1,500. All residents will be responsible for seeking monthly sponsorship with a $750 induction fee due at the time of admission. Some partial scholarships are given based on financial need. Please fill out all forms as honestly and completely as possible to be considered for need based assistance.

How much can you afford of the approximate $1,500.00 monthly program cost?
$/month (12-months)

Check any/all of the following personal assets/income you have and list value:
Vehicles Value
Property Value
401k Value
Child Support Value
Alimony Value
SSI Disability Value
 

Checking Account Value
Savings Account Value
Settlement Payments Value
Trust Fund Value
Other Value
Other Value
Please list all parties contacted and providing payment toward your recovery
Mother's Name
Address
Phone
Email
Sponsorship Amount


Father's Name
Address
Phone
Email
Sponsorship Amount


Grandmother's Name
Address
Phone
Email
Sponsorship Amount


Grandfather's Name
Address
Phone
Email
Sponsorship Amount


Church's Name
Address
Phone
Email
Sponsorship Amount
Sponsor's Name
Address
Phone
Email
Sponsorship Amount


APPLICANT’S CERTIFICATION AND AGREEMENT

By my signature below, I certify that all answers and statements on this application are true and complete to the best of my knowledge. I understand that, should an investigation disclose untruthful or misleading answers, I may be discharged from the New Life For Youth program. Furthermore, I understand that New Life For Youth is a Christian, faith-based program.

Please check the following boxes indicating you have received, read, and agree to abide by the guidelines contained, herein.

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Signature of Applicant
Date

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