SCREENING APPLICATION:

General

First Name: Client first name 

Middle Name: Client middle name 

Last Name: Client last name

Address: Client Address

City: Client City State: Client State Zip: Client Zip

Email: Client email Phone Number: Client phone

Gender: Client gender Birthdate: Client birthdate

School: Client school

Marital status: Client marital status

Number of children:  Text field

Race: Client race

Veteran: Client veteran status

Emergency Contact:  Text field

Emergency Contact Address:  Text field

Emergency Contact Phone Number:  Text field

Relationship with Emergency Contact:  Text field

Attorney's Name:  Text field

Attorney's Contact Phone and Email:  Text field

Desired Move in Date: Date

How did you hear about this ministry?  Text field

What are your life controlling issues?  (i.e. drugs, alcohol, gambling, sex, etc.)  Paragraph

What drugs are you currently struggling with?  Text field

When was the last time you used and what was it?  Text field

Have you attended any other treatment programs or recovery programs for these issues?  If yes, give the name of the facility and when you were most recently there.  Paragraph

If you are incarcerated, please list your charges and/or convictions:  Paragraph

Do you have any pending court cases or legal issues?  If so, please explain:  Paragraph

Are you a registered sex offender?  If so, please explain and include any restrictions you may have:  Paragraph

Have you been convicted of any violent crimes?  If so, please explain:  Paragraph

Do you have any diagnosed medical conditions?  If so, please explain:  Paragraph

Have you been diagnosed with any mental health disorders (bipolar, schizophrenia, etc.)?  If so, are you on any medications?  Please list the diagnosis and medications if so:  Paragraph

How do you plan to pay for your medication while you are a resident at 7 Springs?  Paragraph

Are you able to perform manual labor?  Paragraph

Do you have any physical limitations?  If so, please explain:  Paragraph

Are you a Christian?  If so, how long and what denomination?  Text field

If you are not a Christian, do you identify with any other religion or belief system?  (not being Christian does *not* disqualify you)  Text field

Can you read/write in English?  Text field

What grade did you finish in school?  Text field

Are you willing to complete 12-18 month long program (or more at staff discretion)?  Text field

Are you willing to be mandated by the courts?  Text field

Tell us who you admire most in life and why:  Paragraph

What has been your most pivotal life experience:  Paragraph

What do you hope to accomplish at 7 Springs?  Paragraph