Application Form - Springboard Home for Girls

Program Application

Before filling out this application please read the Springboard Parent Handbook

Complete name of student applying to program(Required)
First Middle Last

Name of Legal Guardian(s)(Required)
First Last

Name of Legal Guardian(s) 2(Required)
First Last

Present Address(Required)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Email

Cell Phone 1(Required)

Cell Phone 2

Other Phone

Prospective Student Personal History

DOB:(Required)
MM slash DD slash YYYY

Is the potential student currently enrolled in school?(Required)

Yes

No

If no, please explain:(Required)

Current Grade Level(Required)

Family Information:

Please check all persons living in the prospective student’s home:(Required)
Biological Mother
Biological Father
Step Mother
Step Father
Adopted Mother
Adopted Father
Grandfather
Grandmother
Brother(s)
Sister(s)
Other

Brother(s) Ages(Required)

Sister(s) Ages(Required)

Other (Explain)(Required)

Have you spoken to the potential student about the Springboard program?(Required)

Yes

No

Stop. You can not submit this form or proceed with the program until you've spoken with the potential student.

Is she interested in recovery?(Required)

Yes

No

Our program is designed for girls who are interested in recovery. We are not a lock down facility and require willing participation from our students. If the potential student is not interested in recovery at this time, please contact our intake coordinator and she can help you with finding other resources.

Has she been involved in church?(Required)

Yes

No

If yes, please list church name(Required)

Is she adopted?(Required)

Yes

No

If yes, when was she adopted?(Required)

Has she ever been in foster care?(Required)

Yes

No

How many children are currently in your home?(Required)

Do you have relatives/friends currently in Teen Challenge programs?(Required)

Yes

No

If yes, which programs?(Required)

Has the potential student been in Teen Challenge before?(Required)

Yes

No

If yes, please list when and where:(Required)

If yes, did she complete the program?(Required)

Yes

No

If no, please list why:(Required)

Issues Profile/Assessment

Please answer the following questions to the best of your ability. We know that you may not have a complete picture of the substance abuse or other history. Please list what you believe the potential student needs help with:

Abandonment(Required)

Current

Past

N/A

Aggression(Required)

Current

Past

N/A

Alcohol(Required)

Current

Past

N/A

Anger(Required)

Current

Past

N/A

Anxiety(Required)

Current

Past

N/A

Death of loved one(Required)

Current

Past

N/A

Depression(Required)

Current

Past

N/A

Drug Addiction(Required)

Current

Past

N/A

Eating Disorders(Required)

Current

Past

N/A

Emotional Stress(Required)

Current

Past

N/A

Family Relationships(Required)

Current

Past

N/A

Fear(Required)

Current

Past

N/A

Forgiveness(Required)

Current

Past

N/A

Physical Abuse(Required)

Current

Past

N/A

Pornography(Required)

Current

Past

N/A

Processing Trauma(Required)

Current

Past

N/A

Rape(Required)

Current

Past

N/A

Rebellion(Required)

Current

Past

N/A

Same Sex Attraction(Required)

Current

Past

N/A

Self-Image(Required)

Current

Past

N/A

Self-Mutilation(Required)

Current

Past

N/A

Suicidal Thoughts(Required)

Current

Past

N/A

Tobacco Addiction(Required)

Current

Past

N/A

Violent Tendencies(Required)

Current

Past

N/A

Other(Required)

Current

Past

N/A

Other (Please Explain)(Required)

Please give a brief description of the following history below including the date and circumstances of the most recent incident:

Death of loved one Details(Required)

Eating Disorder Details(Required)

Self-Mutilation Details(Required)

Violent Tendencies Details(Required)

Medical History

Check all that apply to the potential student’s current and past conditions:(Required)
None
ADD
ADHD
Anorexia
Asthma
Back Problems
Bi-Polar
Bulimia
Depression
Diabetes
Fibromyalgia
Flashbacks
Hallucinations
Head Trauma
Hearing Voices
Heart Condition
High Blood Pressure
Insomnia
Multiple Personalities
Mood Swings
Nightmares
ODD
Other Mental Illness
Paranoia
Physical Abuse
PTSD
Respiratory Problems
Schizophrenia
Seizures
Sexual Abuse
Suicidal Thoughts
Tuberculosis
RAD
STD’s
Hepatitis
Suicide Attempts

STD’s (please list all):(Required)

Hepatitis (what type?):(Required)

Suicide Attempts (number of attempts, when, and how?)(Required)

Substance Use

Does the potential student struggle with substance use?(Required)

Yes

No

Check any and all that you know she has used:(Required)
Alcohol
Amphetamines (uppers)
Barbiturates (downers)
Cocaine
Crack
Ecstasy
Heroin
Huffing/Snuffing
LSD
Marijuana
Meth
Mushrooms
Opioids
PSP
Prescription Drugs
Over the counter medications

Please list prescription drugs that she is abusing, not medication that she is prescribed. Please list all prescribed medications further down the page):(Required)

Over the counter medications (please list only drugs she is abusing):(Required)

What was the last date that your daughter used any of the above substances?(Required)

Drug preference(Required)

Does your daughter vape?(Required)

Yes

No

Does your daughter smoke?(Required)

Yes

No

Additional Comments

Treatment History

Has she ever been in any type of treatment or hospitals?(Required)

Yes

No

Treatment or Hospital History(Required)
Dates (List most recent first)
Treatment center (name and address)
Issues Addressed
Inpatient or outpatient?
Completed?

Select the (+) sign at the end of the last row to add additional rows.

Is she being treated for any medical conditions?(Required)

Yes

No

If yes, please list(Required)

Is she being treated for eating disorders?(Required)

Yes

No

Has she ever been treated by a psychiatrist?(Required)

Yes

No

Has she ever been treated by a psychologist?(Required)

Yes

No

Medications

List all current medications/dosage and list any additional medications taken in the past 5 years. Please indicate if the student is currently taking the medication or not.(Required)
Medication
Dosage
Prescribed For
Current?

Select the (+) sign at the end of the last row to add additional rows.