Midway Recovery Systems
Potential Resident Prescreen Form

Confidential — For Screening Purposes Only
All information shared is private and used only to determine program eligibility and next steps.

⚠️ If you are in crisis, feeling suicidal, or thinking about harming yourself, please call 911 or dial 988 for immediate assistance.
You are not alone, and help is available 24/7.

Contact Information
Full Name: Client first nameClient last name
Date of Birth:Date
Phone Number: Client phone
Email Address: Client email
Current City/State:Client CityClient State
Emergency Contact Name & Number: Client phone

Program Interest

How did you hear about Midway Recovery Systems?
Checkboxes  Other: Text field
Are you seeking residential recovery support at this time?
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Background Information

Are you currently using or have you recently used alcohol or substances?
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If yes, please describe: Text field
Have you ever participated in treatment or recovery housing before?
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If yes, where?Text field
Do you have any current legal requirements (probation, court mandate, etc.)?
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If yes, please explain:Text field

Health & Wellness
Are you currently under medical or mental health care?
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If yes, please list any conditions or medications: Text field
Have you been advised to complete a detox program before entering recovery housing?
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(Note: A detox referral may be recommended to ensure a safe and comfortable transition. This does not disqualify you from the program.)

Employment & Financial Support
Are you currently employed?
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Do you have financial support or the ability to contribute toward program fees?
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(Some residents may qualify for financial assistance or a scholarship, based on individual circumstances.)

Goals
What are your goals for recovery and personal growth?

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Next Steps
A Midway Recovery Systems team member will contact you within 24–48 hours to review your prescreen and discuss the next step toward admission.

Ready to Begin?
Submit this form or call us directly at (770) 227-8975 to complete your prescreen assessment.
We’re here to help — no pressure, no judgment, just support.