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GENERAL INFORMATION ABOUT APPLICANT
Is personally motivated to come to CEM.*
Desires to develop a closer relationship with God.*
Is between the ages of 16 and 25 (female) or 16 and 21 (male).*
Is free from pending legal action.*
Is not required to participate in probation or a diversion program.*
Is able to benefit from a more structured, less complicated environment.*
Desires to work toward emotional and spiritual health.*
Desires to complete academic goals if still in high school.*
Is capable of participating in rigorous physical activities.*
Is free of addictions to alcohol, cigarettes, or drugs, or is willing to detox prior to admission.*
Is not a physical threat to self or others. Does not have a history of violent behavior.*
Please explain any "no" answers above.
Home telephone number*
Applicant's cell phone
Other contact phone number
HISTORY AND FAMILY INFORMATION
Applicant lives with *
Family members (parents and siblings, age of siblings)
PERSONAL SUMMARY AND CHRISTIAN EXPERIENCE
Precipitating problems (reason for applying to CEM)
Does applicant attend church?
Does applicant have medical insurance?*
Describe any medical/physical problems
List all medications applicant is taking
Report both present and previous legal problems. Please include any upcoming court dates, probation, unfinished community service hours, and any other information that would be helpful.
Before submitting, make sure you have filled out all required fields (marked with an *). After submission, you will be sent to a new page with an acknowledgement.