Raw Score for this Application: out of - %

Q1. Please enter the following: First Name, Last Name
First Name:

Last Name:

Q2. I am submitting an application to attend the CAP Restoration Center because of
Moral Failure (Adultery, Fornication, Child Molestation, Homosexuality, Spousal Abuse, Arson, etc.)
Ethical Failure (Greed, Excess, Tax Evasion, Pornography, etc.)
Other Issue

Q3. Please explain, why you chose the moral, ethical, or other issues from the previous question?

Q4. Have you ever had inpatient or outpatient psychotherapy?If so, what was your diagnosis?

Q5. Was the treatment inpatient or outpatient?
Inpatient
Outpatient

Q6. When was your treatment? (MM/DD/YY)

Q7. Where was treatment given?

Q8. What was the method of treatment (counseling, psychotherapy, medications, inpatient stay, outpatient services, etc.)? Please explain.

Q9. Have you been prescribed any psychotropic medications? Yes, what were they?

Q10. Are you currently taking any psychotropic medications (type(s) and dosage)?
Yes
No

Q11. Have you ever been treated for drug (recreational or prescribed) or alcohol abuse? If yes, what type of abuse is/was it?