Fill and Sign the Health Insurance Application Form

Syracuse Teen Challenge P.O. Box 72, 124 Furman Street Syracuse, NY 13205 Phone: (315) 478-4139 Fax: (315) 472-0668 E-Mail: teenchallengesyracuse@gmail.com Web: Syracusetc.com Syracuse Teen Challenge, located at 124 Furman St, is a Christian residential program for men who desire to be free from life controlling problems. Many of the men received at the center have long histories of drug and/or alcohol abuse and were involved in crime. The center works with men who are almost 18 and older. The students are referred by family, friends, churches, agencies, courts and Teen Challenge graduates. Applicants must show a desire to change. They are also expected to be open-minded in seeking a personal relationship with Christ, which is considered necessary to experience a permanent and meaningful change. Syracuse Teen Challenge is a highly disciplined program of scheduled activities including Biblical classroom instruction, work, church, and recreation. In the classroom the students learn how to relate to God, other people and authority figures such as parents, teachers, government officials and employers. They also learn how to deal with anger, rebellion, temptation and failure. Developing personal integrity is another aspect of character growth that is emphasized. Since the program is residential, the students receive the guidance of a dedicated staff and change and growth take place in an atmosphere inspired by the love of God. Individual accountability is encouraged through a concept called LIGHTT (Living In Group Harmony Through Truth). These weekly meetings of staff and students aim to promote unity and help students face their problems rather than run from them. The Teen Challenge program is 12 to 14 months in duration, depending on the individual’s progress. During the first few weeks the student must show a willingness to deal with his problems in order to continue in the program. After completing the first phase in Syracuse, which is termed induction, the students are transferred to the Teen Challenge Training Center in Rehrersburg, Pennsylvania which is about fifty miles east of Harrisburg. During the eight months at the Training Center, the students can study for a GED, receive life skills training and participate in a work therapy program which may include vocational trades such as auto mechanics, printing, carpentry, farming, greenhouse, food services, public relations, and building maintenance. HERE ARE SOME COMMENTS STUDENTS HAVE MADE ABOUT THEIR STAY AT TEEN CHALLENGE ¾ ¾ ¾ “For over fifteen years I was addicted to heroin and cocaine and believed God hated me. After coming to Teen Challenge I learned about the love God has for me. I have been delivered from drugs, a life of crime, and hating myself.” – Sam “Rebellion established at an early age escalated to drugs and crime. I felt life slipping away, the only reality I could see for myself was spending the rest of my life in prison. By admitting my hopelessness to God, He has given me a hope and a future. He is giving me a new life through Jesus” – Mike I had a serious drinking problem and involved with drugs. I came to Teen Challenge because I was filled with coldness, bitterness, and hate. God is teaching me how to love and have a personal relationship with Him.” – Bill A BRIEF LOOK AT THE TEEN CHALLENGE CURRICULUM The national Teen Challenge Curriculum Committee defines several major areas where students should develop. This development is accomplished through group as well as individual classes held weekdays at the Syracuse Center. 1) Authority a) Developing a positive attitude toward people in authority b) Learning how to exercise correct authority over others 2) Responsibility a) Understanding the importance of being a responsible person b) Recognizing irresponsible behavior in self and others c) 3) Relationship to God a) Learning the importance of asking Jesus Christ to be the leader of one’s life b) Applying spiritual principles from the Bible in order to lead an orderly life and overcome problems c) 4) Family/Friendship a) Understanding one’s position and responsibility in a family relationship b) Learning how to restore relations with people 5) Self-Image a) Learning how to have a positive self image b) Realizing how surface problems are often the result of a poor self-image 6) Moral Freedom: Social and Sexual a) Understanding and developing proper steps to moral freedom b) Realizing that God forbids certain behaviors for man’s own good 7) Success/Community Relations a) Understanding the Biblical concepts of success b) Learning how to use failure for growth c) Understanding one’s own personal strengths and weaknesses in dealing with others d) Learning how to relate in the local church community and with non-Christian people ADMISSION CRITERIA ¾ ¾ ¾ ¾ ¾ ¾ ¾ ¾ Applicant must be sincere and desperate about changing his life and willing to make a one-year commitment to completing the Teen Challenge program. He must submit to all rules and be openminded towards a Christ centered program. Since this is a long-term program, individuals who are in need of crisis housing will be referred to the Rescue Mission. All pending legal matters should be resolved before entering the program Applicants must not use any medication for a psychiatric condition. Any pressing health problem (physical or dental) are to be taken care of before entrance. Applicant must be in reasonably good health and remain so to continue in the program. The applicant should be able to participate fully in our classes. Those placed on the waiting list must call in every Tuesday between 10:00am and 3:00pm. TEEN CHALLENGE AGREEMENT Personal ¾ I will not use or possess drugs. Prescriptions by a medical doctor will be kept securely in the office. ¾ I will not smoke cigarettes, drink alcohol, curse or swear ¾ I will not threaten or intimidate others ¾ I understand that I am responsible for exercising self-control daily ¾ I will avoid talking about my old life with others in the program ¾ I am willing to adjust my hair and dress according to the standards of the program, No beards, no jewelry, no symbols of the old life such as t-shirts etc… ¾ I will not leave the premises without a staff member ¾ I understand that physical violence is grounds for immediate dismissal Family ¾ I understand that I may make only one phone call during the first four weeks in the program. After the first month I may make one call per week. ¾ During the first six weeks of the program, I will receive letters from my immediate family only. I understand that I must open my mail in front of a staff member ¾ I will be able to receive visitors after completing four weeks in the program. Visitors will be members of my immediate family only and these visits will be arranged one week in advance Money ¾ I will turn in my money which will be kept in a personal account in a safe ¾ I understand all my purchases will be administered through a staff member FINANCIAL POLICY Concerned individuals privately fund Teen Challenge. Total cost for residential treatment at our center amounts to $1050.00 per student per month. In order to help the program meet its financial obligations, we require three things. 1. Students and/or their sponsors are asked to contribute a non refundable entrance fee of $750.00 when entering the program which is applied to the first month’s cost. 2. I understand that I or my sponsors are responsible to cover any out of town transportation expenses that may be necessary while in the program, e.g. court appearances, medical, dental, etc. 3. The student and/or his referring sponsors are responsible to make arrangements with family members, friends, co-workers, churches, service organizations (Kiwanis, Rotary clubs, etc…) to help cover as much of the $1050.00 as possible for each month of his stay at the center. Your cooperation and efforts in this matter are greatly appreciated. ADMISSION AGREEMENT 1. I understand I will not be admitted if I come high or am suspected of being high 2. I understand that I should arrive at Teen Challenge at the agreed time and date. Failure to do so may result in my being turned away. If for any reason I cannot arrive on the specified date and time, I should call the intake director or leave a message. 3. I understand that I should bring the following items if I can: dress shirts, collared shirts, ties, slacks, slippers or sandals, towels, washcloths, pillow and sheets. 4. I will NOT bring the following items: tobacco products, books, dice, cards, tapes, magazines, audio equipment, or weapons 5. I understand that my belongings will be thoroughly searched on the day of admission. 1. I understand that I will need the following with me: a. Social Security Card and a copy of my birth certificate b. Driver’s License or Photo ID c. Entrance Fee of $750.00 d. Names, addresses and phone numbers of probation and parole officers, attorney or public defender. e. Full information regarding court appearances: date, time, court, judge, etc… f. Names, addresses and phone numbers of all immediate family who might visit, call or write, while I am in the program. g. If I am presently receiving any help from Social Services, I will inform them that I am entering this program. I will instruct them to designate my housing allowance to Syracuse Teen Challenge at our address. 2. I understand that I may be asked to take a shower immediately after being checked in. PLEASE KEEP THIS PAGE WITH YOU UNTIL YOU REACH TEEN CHALLENGE Please bring a copy of the following medical tests which have been done within the past 6 months: ¾ ¾ ¾ ¾ Physical Exam (Health Screen) TB Skin Test (if positive, bring paperwork on the follow up test) VDRL (RPR) Liver Function (Hepatic Panel Only) PLEASE NOTE: Teen Challenge is not responsible for any medical bills acquired while in the program. If the student leaves the program prematurely, Teen Challenge is not responsible for any personal belongings left here beyond 24 hours. Syracuse Teen Challenge Contact Information: Intake Coordinator: Brian L. Ferguson Phone: Fax: (315) 478-4139 (315) 472-0668 SYRACUSE TEEN CHALLENGE P.O. BOX 72, 124 FURMAN STREET SYRACUSE, NY 13205 PHONE 315 478-4139 FAX 315 472-0668 E-MAIL: TEENCHALLENGESYRACUSE@GMAIL.COM WEB: WWW.SYRACUSETC.COM APPLICATION Name: ________________________________________________________________ Date: ___________________ Address: _______________________________________________________________________________________ City / Town: _____________________________________________ State: ____________ Zip: ________________ Phone: (______) _______-_______ Work Phone: (______) _______-_______ Age: ______ Race (opt): ______ Birth Date: _____ / ______ / ______ SSN: _______ - ____ - ________ Ht: ______ Wt: ______ Eyes: _____ Birth Place: __________________________ Where were you raised: ________________ Marital Status: ________ Recently, who has been supportive of you? ___________________________________________________________ Wife / Fiancé name and address: ___________________________________________________________________ Emergency Contact name and address: ______________________________________________________________ Referring Person / Agency name, address, and phone: _________________________________________________ Have you ever spent time in a hospital for mental health? YES: _____ NO: _____ If Yes, where: _________________________________ When: _______________ How Long: _________________ Have you ever seen a psychiatrist or psychologist? YES: _____ NO: _____ Frequently: _____ Infrequently: ____ Name TWO traumatic (negative) experiences from your past including childhood. Be sure to include where, and how long these experiences lasted. 1. _____________________________________________________________________________________________ 2. _____________________________________________________________________________________________ Briefly share any person or anything that you are especially concerned about or troubled about: ______________ _______________________________________________________________________________________________ Who is the person that wants you to enter Teen Challenge? _____________________________________________ Age of st DRUG AND SUBSTANCE HISTORY How many Used within Last used How Taken? Drug: 1 use times a wk last 30 days month/yr oral IV Smoke Snort Alcohol ________ _________ _________ ___ / ___ [ ] [ ] [ ] [ ] Amphetamines ________ _________ _________ ___ / ___ [ ] [ ] [ ] [ ] Barbiturates ________ _________ _________ ___ / ___ [ ] [ ] [ ] [ ] Cocaine / Crack ________ _________ _________ ___ / ___ [ ] [ ] [ ] [ ] Codeine ________ _________ _________ ___ / ___ [ ] [ ] [ ] [ ] Glue ________ _________ _________ ___ / ___ [ ] [ ] [ ] [ ] Heroin ________ _________ _________ ___ / ___ [ ] [ ] [ ] [ ] LSD / Acid ________ _________ _________ ___ / ___ [ ] [ ] [ ] [ ] Marijuana ________ _________ _________ ___ / ___ [ ] [ ] [ ] [ ] Antidepressants ________ _________ _________ ___ / ___ [ ] [ ] [ ] [ ] Psychotropic ________ _________ _________ ___ / ___ [ ] [ ] [ ] [ ] Other ________ _________ _________ ___ / ___ [ ] [ ] [ ] [ ] First Experience: Age: ______ Type of Drug: ______________ With Who: _________________________________ Why did you start doing drugs / alcohol? _____________________________________________________________ _______________________________________________________________________________________________ What is the longest time you have gone without drugs or alcohol since you started using? __________ How did you accomplish this? ______________________________________________________________________ What prescribed drugs or over-the-counter medications are you currently using? ___________________________ Have you ever tried to commit suicide or thought about it? YES: _____ NO: _____ If Yes, Explain: __________________________________________________________________________________ Do you have special dietary needs: YES: _____ NO: _____ Explain: ______________________________________ Do you have any medical problems: YES: _____ NO: _____ Explain: _____________________________________ What have you done for past treatment? (AA, NA, Antabuse, Detox, etc…) Program _____________________________ _____________________________ _____________________________ Dates ___________ ___________ ___________ Comments _____________________________________________________ _____________________________________________________ _____________________________________________________ Have you ever been in trouble with the police? YES: _____ NO: _____ Current Charges: YES: _____ NO: _____ Are you currently serving a sentence? YES: _____ NO: _____ Have a criminal record? YES: _____ NO: _____ If Yes, describe charge(s), court(s) and court status below: Date ___________ ___________ ___________ City and State _______________________ _______________________ _______________________ Charge _______________________ _______________________ _______________________ Outcome _______________________ _______________________ _______________________ Age ___________ ___________ ___________ Have you ever spent time in jail? YES: _____ NO: _____ If in a State or Federal prison, when where you released? ________________________ List probation / parole officers, social workers, attorney with phone number Name _______________________ _______________________ _______________________ Phone _______________________ _______________________ _______________________ Name _______________________ _______________________ _______________________ Phone _______________________ _______________________ _______________________ Why did you turn to Teen Challenge? _______________________________________________________________ _______________________________________________________________________________________________ Why are you seeking help now, rather than six months ago? ____________________________________________ _______________________________________________________________________________________________ What was one of the most painful experiences in your life? ______________________________________________ _______________________________________________________________________________________________ List three problem areas that you would like help with while at Teen Challenge? 1. _____________________________________________________________________________________________ 2. _____________________________________________________________________________________________ 3. _____________________________________________________________________________________________ List any church involvement: ______________________________________________________________________ If you are successful at Teen Challenge, describe what you hope to be like when you complete this program. _______________________________________________________________________________________________ _______________________________________________________________________________________________ How many months are you willing to invest getting help? ___________________ I have read the policies and Admission agreements of Teen Challenge and I am willing to abide by them. Signature: __________________________________________________ Date: _____________________________