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Application Page

APPLY TO

FRESH START

Please fill out the application form below.

Give Teens A Fresh Start

First name

Last name

Email address

Phone

Address

Emergency Contact Details:

Please provide emergency information for at least one other contact in addition to the parent / legal guardian.

First name

Last name

Email address

Applicant (Minor) Details and History:

First name

Last name

Email address

Phone

address

Date of Birth

Please indicate your teen’s areas of struggle and what you hope for them to achieve through this program:

Any history of drug, alcohol, or substance abuse?

Yes

If so, what substance

Any history of drug, alcohol, or substance abuse?

Yes

If so, what substance

Free Text

*These are not disqualifications from our program but help us to know about your teen’s needs and challenges.

I Am Applying For (Select One):

Fresh Start Academy Preventative Care  - Our Preventative Care program is designed for teens who need support before issues escalate. This program provides proactive guidance and accountability, helping to steer your teen away from potential pitfalls and toward a healthier future.

Fresh Start Transitional Program - This program supports teens transitioning back to everyday life after completing a drug rehab program or juvenile detention. It focuses on rebuilding their lives with structure, guidance, and ongoing support to prevent relapse and promote long-term recovery.

Where did you transition from? (Select one):

Drug rehab program

Juvenile detention center

Other: __________

Name of Program:

Dates Entered:

Name of Supervisor:

Did You Graduate?:

Yes

Emergency Contact Details:

Enter your free text here

Are you willing to attend church weekly with your teen?

Are you willing to support your child in this program?

Yes

Will you commit to the financial investment?

Yes

Thank you for contacting us.
We will get back to you as soon as possible.

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Home
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ENROLL NOW

PO BOX 2327 Virginia Beach, Va 23450

757-792-1908

PO BOX 2327 Virginia Beach, Va 23450

757-792-1908

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