CHRISTIAN DISCIPLESHIP
90-DAY RECOVERY PROGRAM
APPLICATION FORM
Name_____________________________________________
Home Phone__________________ Cell Phone_________________________________
Address____________________________________________________City____________________________
Zip Code___________________ EMAIL Address:_______________________________________________
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?_________________________________________
LEGAL HISTORY
Have you ever been convicted of a crime? Yes______ No_____
List convictions __________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
Did you serve time? Yes______ No_______
How Long? _________________
Are there any charges pending against you?_____
Explain:_____________________________________________________________________
Your Probation officer or Public Defender__________________________________________
Their phone no.________________________
Do you have a scheduled court appearance in the next several months? ___
If so, what date? _______________
Have you ever been arrested or convicted for a sexual crime? ___
If so, 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?________
Are you using tobacco products? _____ What kind? _______________
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.___________________________________________________
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_____ Open sores_____
Dizziness_____ Memory loss_____
Liver problems_____ Eye problems_____
Panic Attacks_____ Trouble sleeping_____
PTSD______ Bipolar Disorder______
Depression_____ Stress_____
Stomach Problems_____ Hepatitis_____
Heart Problems_____ HIV Infection_____
Seizures_____ Weight loss_____
Are you presently on any medication?_____
If yes, what kind(s)?____________________________________________________________
Do you have any disabilities?_____
If yes, explain:__________________________________
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_________________
A background check is obtained for all applicants prior to their acceptance.
Give your social security number here ____________________ and by your signature below give your consent.
Name signed
_____________________________________________________________________________________________________________________
COST PLAN
The Christian Discipleship three-month residential Recovery Program is supported through
donations, and all of our staff serve without salary. All of the instruction, counseling and materials
are provided freely. The only fee that is charged is the applicant’s contribution toward his room
and board.
Because scholarship money is now available, the cost for attending CDC has been greatly reduced.
(The full cost of room and board that would be paid by a tribal agency is $800 per month.) When
an applicant pays for himself, he can come with $500 for the first month’s fee, and a scholarship
will cover the second and third month of enrollment. For those with greater need, the payment
plan can be adjusted by paying only $200 each month of enrollment, and the scholarship will
cover the rest of the room and board charge.
It is important to send in the application as soon as possible for review and acceptance. Then each
applicant or his family can work out a financial arrangement later with our CDC director.
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CLIENT ACCEPTANCE FORM (Select one below)
_____ I am a Native American in need of your scholarship. I agree to pay $500.00 for the first month if I qualify. I understand that the 2nd and 3rd months will be covered by the scholarship. Signed_________________________ Date__________
_____ I do not qualify for scholarship. I agree to pay $800 per month for my enrollment.
Signed_____________________________ Date_____________
[NOTE: First payment is due upon arrival and each following month]
_____ My enrollment fee is being paid by a Tribal, government, health or other agency.
Signed____________________________ Date_______________
Here is the name, phone number and contact information for the person authorizing
the payment from the agency:
* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *
Mail to: CHRISTIAN DISCIPLESHIP CENTER
24826 Road L Cortez, CO 81321
or Fax to (970) 564-9328
or Email to CDC@fone.net
For questions, please call: 970-565-3290