PRE-ASSESMENT FORM

**Please fill out form in its entirety, incomplete applications will be disregarded**

 

Client first nameClient last name         DOB: Client birthdate

 

Place of Birth: Text field 

Client phone       Client email

 

Gender: Dropdown

                  

How did you hear about us?  Text field

 

Client substances of choice          Date of last use: Date

 

Marital Status: Client marital status         

Spouse/Family Addiction History: Paragraph

 

List Recovery Experience: Paragraph

 

 **Please Note questions asked are not to disqualify, only to ensure we are able to asssist in providing each individual with the appropriate and proper care**

List Physical Health condtions: Paragraph

Height Text field  Weight Text field

 

List all medications: Medication

 

 

List Mental Health condtions: Paragraph

 

Self Harm History: Paragraph

 

 

 EmploymentHistory

 

Have you ever experienced homelessness: Text field

 

Describe your faith: Text field

 

Are you a US Citizen?  Dropdown

 

Do you have a valid ID?  Dropdown

 

Identification Number: Text field

 

Are you a Veteran? Dropdown

 

Do you have a birth certificate/social security card? Dropdown

 

Do you have a working phone? Dropdown

 

Current Probation Status/Probation Officer Information: Paragraph

 

 Criminal History

List Criminal History: Paragraph

 

Are you mandated to complete a program?  Dropdown

 

Do you have any active warrants?  Dropdown

 

Do you have any gang affiliations?  Dropdown

 

Are you a listed sex offender?  Dropdown

 

Do you have your own transportation?  Dropdown

 

What is your preferred method of payment? Dropdown

 

Signature