Home Phone__________________  Cell Phone_________________________________
ZipCode___________________      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?_________________________________________

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?_____
Your Probation officer or Public Defender__________________________________________
His 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:_______________________________________________________________

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?_____

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_____
Are you presently on any medication?_____
If yes, what kind(s)?____________________________________________________________
Do you have any disabilities?_____
If yes, explain:__________________________________

Are you a Christian? _____________
When did you receive Christ as Savior?___________________________________________
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, Godís Word. Do you desire Godís 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?

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

The Fee for the CDC program applies only to the housing and meals. The Recovery Program (instruction, counseling, materials, etc.) is subsidized through donations, and our staff offer their services without charge to CDC.
If a client self-pays, there is a subsidized Program Fee of $400 per month or $1200 for the complete 90 days (The Actual Cost is $2100 for 90 days; a scholarship of $900 is included in self-pay).
The following are sources of income which enable a client to contribute toward the Program Fee for his enrollment:
Employment Income __________
SSI or SSDI Monthly Income __________
Tribal Allotments, Dividends __________
Contribution by family __________
Contribution by church or sponsor __________
Other __________
Total $__________
If any or all of the above amounts are equal to or greater than the $400 per month for the room and board charges, the Client will pay the Program Fee of $1200 for enrolling in the program.
If a Tribe or other government or health agency is paying for the clientís enrollment, an invoice must be mailed directly from CDC to such agency, and the full, unsubsidized Fee (Actual Cost) of $2100 will be assessed.
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Client Acceptance Form
I understand this Cost Sheet, and I agree to pay the following amount each month for my enrollment in the CDC Program: $_________________

Date______________ Signed_______________________________________

My enrollment is being paid by the following Tribe or Agency. Please bill them directly at the following address:

Mail to:
Christian Discipleship Center
24826 Road L
Cortez, CO 81321

or Fax to (970) 564-9328