Date 

Name 

Address 

City    State 

Phone 

Referred by 

Date of Birth     Age:    

Race:  White   Black    Other 

Sex:  Male    Female    Marital Status   

No. of children 

Religion    Occupation 

Education   

Medications 

Health Issues 

Do you have any court dates pending?  yes    no 

If so, when?    Where 

Lawyer's name    Lawyer's phone number 

Are you on supervised or unsupervised probation/parole?  yes    no 

Name of probation officer    phone number 

Reason for entering program 

Have you ever been in a Teen Challenge program?  yes    no 

If so, when?    Where 

Reason for leaving 

Have you ever been or are you presently in counseling?  yes    no 

When    Where