Online Student Application for Faith Farm Programs
Last Name First Name MI
Referred to Faith Farm By
Address of Contact City
State Zip Phone Number
Emergency Contact Person Relationship
Date of Birth Age Marital Status
Height Weight Eyes Hair
Where do you live? Schooling Completed? Middle School High School College Select One
Do you receive government benefits? YES NO Select
Describe your religious/spiritual experiences :
Substances Regularly Used
Substance
Years Used
Last Used
Alcohol
Cocaine
Marijuana
Hallucinogens
Speed
Heroin
Other
Longest time sober in past 3 years? in the last year? Pattern of usage Losses due to usage Physical effects of abuse
Any Previous Rehabs? YES NO Select Ever been to a Faith Farm Before YES NO Select
Year: Where: Boynton Beach Ft. Lauderdale Okeechobee Select One How would you rate your health? Excellent Good Average Poor Select one Are you on medications? YES NO Select Do you have a 30 day supply? YES NO Select
Do you have any kind of appointment in the next 30 days? YES NO Select During the past five years have you: Been treated for or told you have sickness or injury? YES NO Select If yes, give details.
Have you had any injuries to back? YES NO Select If yes, explain:
Do you wear glasses YES NO Select Contact lenses YES NO Select
Constantly YES NO Select Reading only YES NO Select Do you have any bumps lesions or cuts YES NO Select explain
Have you ever had any of the following:
Arthritis or Rheumatism YES NO Select Polio YES NO Select Dizziness or Fainting spells YES NO Select
Back Surgery YES NO Select Head Injury YES NO Select Diabetes YES NO Select High Blood Pressure YES NO Select Epilepsy YES NO Select Kidney or Bladder Trouble YES NO Select
Asthma YES NO Select Phlebitis YES NO Select Varicose Veins YES NO Select Knee Injury YES NO Select
Back Injury YES NO Select AIDS YES NO Select Loss of Hearing YES NO Select Herpes YES NO Select
Loss of sight in one eye YES NO Select HIV YES NO Select Hepatitis YES NO Select Rupture YES NO Select
Which side Was it operated on? YES NO Select Date
Physician Have you ever been sued? YES NO Select
Are you involved in a lawsuit? YES NO Select Date
Details How many Felonies have you been convicted of? Name them: Are you on probation? YES NO Select What County? Probation Officers Name:
Probation Officers Phone #: Any Court or Probation appointments in the next 30 days? YES NO Select
Dates & Times
Employment History Employee Duties And Dates Worked
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