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Online Application Form

Get Help Today!

Submitting a program application to Teen Challenge Canada is simple. Fill out the information required below, submit your application, and one of our admission coordinators will be in touch with you. Acceptance of your application will be dependent on meeting all admission requirements.

If you are accepted, you will be placed on a waiting list pending available space. When a bed becomes available, your entrance day will be scheduled. To maintain your position on the waiting list, you are required to call us weekly to demonstrate your continued interest in the program. Please note, depending on availability, you may be asked to participate in a program at a centre in a province outside of your residence.

STEP 1

Provide us your contact information.

STEP 2

Tell us about yourself and your current circumstances.

STEP 3

Process your form...easy as 1,2,3

Contact Information

First Name *

Middle Name

Last Name *

Address *

City *

Country * Province * PC * Select Canada United States Select

Date of Birth * MM Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec DD 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 YYYY 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

Email Address *

Primary Phone Number *

ok to leave a voicemail message? * YES NO

Secondary Phone Number

ok to leave a voicemail message? YES NO

Are you completing this application for someone else? * YES NO

Please provide your contact information.

First Name *

Last Name *

Phone Number *

ok to leave a voicemail message? * YES NO

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What is your first choice for a treatment Centre

Please select one Alberta Men's Centre Atlantic Hope Women's Centre Atlantic Men's Centre Eastern Ontario Men's Centre Ontario Men's Centre Ontario Women's Centre Prairie Hope Women's Centre Saskatchewan Men's Centre

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Are you 18 years of age or older? * Yes No

Do you have a drug or alcohol abuse problem or addiction? * Yes No

Are you open to a Christian faith-based approach to treatment? * Yes No

Are you open to a 12-month commitment to treatment? * Yes No

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Is someone else forcing you to seek help? * Yes No

Do you have disabilities that would prevent full participation in regular physical activities? * Yes No

Do you have any other psychiatric conditions? * Yes No

Do you have a medical condition that is contagious to others? * Yes No

If you are female, are you pregnant? * Yes No

Do you take medications? If so, what (please enter in comment box below)? * Yes No

Do you have outstanding warrants? * Yes No

Are you on parole? * Yes No

Are you currently in jail, prison, or other detention facility? * Yes No

Do you have outstanding court or legal issues? If so, what (please enter in comment box below)? * Yes No

Are you listed on the National Sex Offender Registry? * Yes No

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ANYTHING ELSE WE NEED TO KNOW? MEDICATION? LEGAL? HEALTH CONCERNS?

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Please check the box below

SUBMIT APPLICATION