CHRISTIAN DISCIPLESHIP CENTER
90-DAY RECOVERY PROGRAM
APPLICATION FORM
Name_____________________________________________ Phone__________________
Address____________________________________________________Zip_____________
Tribe_________________________________ Other Race_______________________________
Age____________ Date of Birth___________
Status: Single_____ Married_____ Divorced_____ Separated_____ Engaged_____
Living with unmarried partner_____
Do you have any children?_____ How many?_____
For what problem(s) are you seeking help?_________________________________________
Are there any charges pending against you?_____
Explain:_____________________________________________________________________
Your Probation officer or Public Defender__________________________________________
His phone no.________________________
Are you presently on any medication?_____
If yes, what kind(s)?____________________________________________________________
Are you allergic to anything?_____
If yes, explain:__________________________________
Do you have any food restrictions?_____
If yes, explain:__________________________________
Do you have any disabilities?_____
If yes, explain:__________________________________
SUBSTANCE ABUSE HISTORY
When did you drink last?__________________________
What were you drinking?__________________________
When did you first start drinking?___________________
What drugs have you been taking?__________________________________________
When did you first start taking drugs?________________
Have you ever received counseling for your drinking or drugs?________
Have you been in the Armed Forces?_____
What was the highest grade you completed in school?__________
How did you hear about CDC?__________________________________________________
Have you attended other programs?_____
Where?
1.___________________________________________________
2.___________________________________________________
3.___________________________________________________
4.___________________________________________________
MEDICAL HISTORY
Check any of the following that you have had in the last TWO years:
Allergies_____ Asthma_____
Bleeding_____ Diabetes_____
Diarrhea_____ High Blood Pressure_____
Bad back_____ Constipation_____
Dizziness_____ Memory loss_____
Liver problems_____ Eye problems_____
Open sores_____ Trouble sleeping_____
Depression_____ Stress_____
Stomach Problems_____ Hepatitis_____
Heart Problems_____ HIV Infection_____
Seizures_____ Weight loss_____
SPIRITUAL HISTORY
Are you a Christian? _____________
When did you receive Christ as Savior?___________________________________________
Where?_____________________________________________________________________
What church do you attend?_________________________________
Name and address of your pastor_________________________________________________
Phone Number of your pastor________________________________
The Christian Discipleship Center is primarily a spiritual program based upon the Bible,
God’s Word. Do you desire God’s answer to your problems, and are you willing to follow what you will learn from the Bible?_______________________________________________Please Answer the following questions:
Y N Are you having financial problems?
Y N Are you having marriage problems?
Y N Are you having family problems?
Y N Are you having court problems?
Y N Are you having problems knowing if you are saved (a Christian)?
Y N Have you ever attempted suicide?
REQUIREMENTS FOR ADMISSION:
Our program is being offered at minimum cost to you and is supported by the gifts of those interested in the program. All successful applicants must commit to the following requirements.
Check each one and sign below:
1_____ That you will remain in the program for a period of 90 days.
2_____ That you are not allowed to leave the grounds without a staff member present.
3_____ That for the first TWO weeks there will be no communication with anyone outside
the program (except for emergency).4_____ That you will make an effort to apply yourself in all phases of the program.
5_____ That you will abstain from all alcohol, drugs, and tobacco.
6_____ That you will submit to the authority and direction of the staff.
7_____ That you will commit yourself to daily Bible reading, study and prayer.
8_____ That you will consent to a search of your person and possessions when you arrive
and anytime while you are in the program. (Items forbidden in the handbook will be taken away).9_____ That you will consent to random alcohol and drug testing while in the program.
10.____ Any violations of the rules will be grounds for discipline and/or dismissal.
I hereby agree to submit to the above conditions.
____________________________________________ Date_________________
Name signed
COST PLAN AGREEMENT
The Actual Cost of the CDC program applies only to the housing and meals. It is $900 for
90 days, or $300 per month. The instruction, counseling, materials, etc. are subsidized through donations, and our staff offer their services without charge to CDC.The Program Fee for you is determined according to your need and the ability of yourself, your family, church or tribe to pay the Actual Cost. The minimum program fee you can pay is $100 per month of enrollment.
The following are the sources of income which enable you to pay part or all of the Actual Cost:
Employment Income $__________
SSI or SSDI Monthly Income $__________
Tribal Allotments, Dividends $__________
Contribution by family $__________
Contribution by church or sponsor $__________
Payment by Tribe, Chapter, etc. $__________
Other $__________
Your Total Ability $__________
If any or all of the above are equal to or above the $300 per month for room and board costs, then you will pay the actual cost. If these sources are inadequate or unavailable, then you will pay whatever you can (but never less than $100/month).
Personal Acceptance:
I understand this cost sheet, and I agree to pay the following amount each month for my
Enrollment in the CDC program: $_______________Date_______________ Signed_____________________________________________