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This application must be completed in its entirety. Return it by regular mail with the following: 1) Physician-signed Medical Records Form, 2) Copies of all Reports from Mental Health Providers, if any, 3) $50 non-refundable Application Fee to : New Life Girls' Home (Canada) P.O.Box 149, Consecon, On K0K 1T0 ATTN: Program Director
Date of Application: ________________________ Date Available for Trial Period/Program Entry: ______________________________
Last Name: First Name: Address: Date of birth Phone Number (s) Email Address Age
If you could, “sum up" why you are applying to New Life. Please check off the top reasons and where appropriate, please explain ;
ALCOHOL DRUGS SELF ABUSE SMOKING SEXUAL PROBLEMS LAW BREAKING EATING DISORDER ADD/ADHD PERSONALITY DISORDER MOOD DISORDER PANIC DISORDER COMPULSIVE BEHAVIOUR PHOBIAS FINANCIAL PROBLEMS SUICIDAL OTHER
Health card # Marital Status: Single Separated Widowed Emergency Contact Relationship Address
Social Insurance # Married Engaged Divorced Common-Law
How did you hear about New Life Girls’ Home? How are you supported? Family Self Social Services
Please describe your reading and writing skills Reading: Writing: Excellent Excellent Good Good Fair Fair yes no Poor Poor
Do you need assistance reading and or writing? Is English your primary language? If not, what is your primary language?
What is the last school year completed? _________________________________________
College or University, (please list diploma or degree received)
How would you describe your academic skills?
Spouse's Name: Occupation: Address: Home Phone: Date of Marriage: Have you been previously married? Work Phone:
If yes, please explain the reason for separation or divorce
Do you have children?
If yes, please provide details
no Age: Age: Age:
Name: Name: Name:
Who will care for your children while you are at New Life Girls' Home? Name: Relationship: Phone #: Address:
For the purposes of this application, please consider “family” to be the group of people you were raised with, including any stepparents, half-siblings, adoptive parents and long-term foster parents. Are your parents still alive? Father: YES Mother: YES
Are your parents still living together? YES NO If not, what is the nature of their relationship and where are they living?
If they are separated or divorced, what was the cause?
Were you raised by someone other than your natural parents? If yes, whom and why? Do you have brothers and/or sisters? # Brothers # Sisters What is your parents’ religious affiliation? Do your parents attend church regularly?
YES NO YES NO
Is your family supportive of you coming to New Life Girls’ Home?
Information on Family & Friends
Are any of your family member’s currently using/abusing drugs or alcohol? Please explain
Are any of your friend’s currently using/abusing drugs or alcohol?
Most Some Few None Don't know
Denominational Affiliation (if any) How often do you attend church? Do you believe in God? Do you believe in Jesus?
yes yes no no unsure unsure yes no unsure
Do you believe in His Holy Spirit? Have you surrendered your life to Jesus? Do you believe the Bible is God’s Word?
If so, when?
yes no unsure
Are you now, or have you ever been, involved in a cult or the occult?
yes no unsure
Please check if you have ever been involved with or participated in the following: Horoscopes Black Magic Witchcraft Tarot cards White Magic Meditation Ouija Boards Satanism Astral Projection ESP Seances Other
Background on Illegal Activity
Have you ever been in jail or prison? If yes, please explain
List all past charges (felonies & misdemeanours)
1 2 3 4 5 6 7 8
Do you have any charges pending? If yes, please explain
Are you currently on probation? Yes No If yes, please provide name and contact info of your Parole Officer NAME: CONTACT #'s:
Were you abused in any way as a child? Yes No
If yes, please identify who abused you and for how long: Physically Sexually Mentally Emotionally Have you ever abused yourself in any way? If yes, how, why and when? Yes No
Have you ever been abused as an adult? If yes, when, how and by whom?
Have you ever been raped? If yes, when and by whom?
Have you evere participated in homosexual activities? If yes, please explain
Would you consider yourself heterosexual, homosexual or bisexual?
How long have you identified yourself this way?
Have you ever been involved in prostitution? If yes, when and for how long?
Have you used illegal drugs? Yes No If yes, when was your first experience with drugs and what did you use?
Why did you become involved with drugs?
Please fill in the chart below DRUGS USED AGE FIRST TRIED ALCOHOL MARIJUANA BARBITURATES COCAINE HEROIN LSD PCP OPIUM MORPHINE HASHISH QUAALUDES SOLVENTS CIGARETTES PRESCRIPTION OTHER
HOW OFTEN USED
USING NOW ?
As a result of your substance abuse have you ever experienced any of the following? Health Problems Legal Problems Financial Problems Being abusive Yes or No Yes or No Yes or No Yes or No Difficulty completing tasks? Blackouts, forgeting, difficulty thinking Mood/personality changes, flashbacks Relationship Problems Yes or No Yes or No Yes or No Yes or No
Emotional Health We Require Copies of all Reports from all Mental Health Providers
Do you suffer from or have you ever been diagnosed for depression? If yes, please explain. Yes No
Do any immediate family members have a history of depression? If yes, please explain.
Have you ever had a major emotional upset? If yes, when, why and for how long?
Did you receive therapy or treatment for it? Were you hospitalized for it? Yes No Yes No Yes No No
Did you participate in Psychiatric Group Therapy? Did you respond to these treatments? Yes
Have you ever been diagnosed with a mental illness? If yes, name of illness. Have you ever been institutionalzed? If yes, why, how often and for how long? Yes No
What institutions were you in? Please give dates.
Have you ever tried to commit suicide? If yes, how many times, when and why?
Doctor's Name: Address: Phone #:
Do you have any type of medical Insurance? If so, please give details:
Are you on any type of disability or welfare assistance? What is the date and results of your last medical examination?
How would you describe your current physical health? Excellent Good Have you had any recent weight changes? If yes, describe the changes: Height Hair colour Lost Yes
Poor No Gained Eye Colour
Please list all present/past illnesses, injuries and hadicaps that impact you from enjoying and average physical lifestyle.
How have you been sleeping?
How many hours per night (average) have you been sleeping? How is your appetite? List all allegies Good Fair Poor
When was your last tetanus shot? Have you ever had an abortion? If so, how many, what type and when?
Have you ever had syphilis, gonorrhea or any other venereal disease? If so, which one(s), when, for how long and did you receive medical treatment?
When was your last menstrual period? Have you ever had a miscarriage? If yes, when Have you had any intimate sexual contact in the past 2 weeks? Yes No
Have you had a V.D., T.B. or pregnancy test in the past two weeks? If yes, please explain:
Please list ALL medication (including vitamins) that you are currently taking, and for what reason?