Ending Addiction & Modeling Christ
804-451-4481 info@regenesislife.org
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Recovery Program Application

Regenesis is at a minimum a 9 month residential personal development program. Regenesis is a rigorous working program with 24 hour a day supervision. The counseling at Regenesis is biblically based and the rules and standards are rooted in the Christian faith. The use of nicotine products or psychotropic medications are not permitted at Regenesis.

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Student Enrollment Packet

PERSONAL DATA AND INFORMATION

Address
Address
City
State/Province
Zip/Postal
Sexual Orientation:
Do you have a valid driver's license?

NEXT OF KIN/IN CASE OF EMERGENCY

Address
Address
City
State/Province
Zip/Postal
Address
Address
City
State/Province
Zip/Postal

WHO HAS REFERRED YOU TO REGENESIS?

Address
Address
City
State/Province
Zip/Postal

PERSONAL FAMILY HISTORY

Please list parent/parenting figures, spouse, girl/boyfriend, brothers & sisters (do NOT list your children).

PERSONAL & FAMILY MEDICAL HISTORY

Do you have or have you ever had any of the following:
Do you have any diet requirements?
Are you presently taking medication or have open prescriptions?
Address
Address
City
State/Province
Zip/Postal

MARITAL/INTIMATE RELATIONSHIP HISTORY

Marital Status
Address
Address
City
State/Province
Zip/Postal
Do you have any children?

SIGNIFICANT LIFE EVENTS

Describe any of the following that you are experiencing or have recently experienced.

WORK AND EDUCATION HISTORY

Last year of education completed:
College:
Can you write?
Can you read?

PSYCHOLOGICAL HISTORY

Have you ever received mental health treatment?
Have you ever thought about committing suicide?
Are you currently thinking about committing suicide?
Have you ever received psychiatric care?
Have you ever cut yourself?
Have you ever had an eating disorder?
Will you be willing to authorize doctors or agencies involved in previous treatments to release your medical records?

SPIRITUAL HISTORY

Are you a member of any church?
Have you, your parent or grandparents ever been involved in any occult, cultic, new age or any other non-Christian practices?

LEGAL HISTORY

Are you legally mandated to participate in a residential program?
If yes, by whom?
Are you currently or will you be under legal supervision?
Method of reporting:
Address
Address
City
State/Province
Zip/Postal
Are any of the following pending against you? (Please check those that apply)

List all arrests and major convictions other than traffic violations:

Conviction?
Were Alcohol or Drugs Involved?
Add another Remove

Please list all upcoming court dates below:

Add another Remove

FINANCIAL STATUS

Are you eligible for and/or receiving the following:
Have you ever applied for food stamps?

THE PROBLEM

Drug

If you did not use drug listed leave blank.

First Time

How old were you or what month/year?

Last Time

Please list approximate date of last use.

Frequency

How often did you use: occasionally, monthly, weekly, daily, etc.

Amount Used

How much did you use per day/week/month?

Alternate

*If the application form has been completed or filled out by anyone other than the student applicant, please provide the following: