Pre-Resident Screening Form








Marital Status:
singlemarriedwidoweddivorced

Have you ever been in the military?
yesno

Do you receive social security or disability payments?
yesno

Highest education level completed?
Grade schoolMiddle schoolHigh schoolCollegeTrade schoolGED

Do you consider yourself:
AlcoholicDrug AddictBothNeither

What are your drugs of choice?
AlcoholBarbituratesCocaineHeroinMarijuanaAmphetaminesOpiatesPCPK2/SpiceSynthetics

Are you in treatment at the present time ?
yesno


Are you currently incarcerated?
yesno


Are you a sex offender?
yesno

Will you have an electronic monitor?
yesno

Any aggravated charges? (this includes all robbery, murder, and bodily injury charges)
yesno

Are you (or will you be) on Probation or Parole?
yesno

Probation/Parole Officer Name

Contact phone number:

Any charges pending ?
yesno

If yes, please explain

Are you taking any prescribed medication ?
yesno

If YES list all medications and the reason for taking them:

Have you EVER tested positive for any communicable disease?
HIVTBHerpesHepatitisOther

When were you last tested?

Describe all tattoo’s you have:

Have you ever been associated with any gangs?
yesno

Have you ever thought of committing suicide?
yesno

If YES, when ?

Have you ever attempted suicide?
yesno

If YES, when?

What is your profession or skill?

Are you employed locally?
yesno

If “yes”, where?

Who should we contact in case of an emergency?

Name:

Address:





How do you plan to pay program fees?
WorkSSI/DisabilityUnemploymentOther

Please explain



How did you hear about The H.O.W. Center?
Treatment CenterAA/NA GroupProbation/Parole Dept.GoogleReferring Website

Who can we thank for referring you?

Add Any Additional information we need to know or you need to explain regarding any of the application questions here:

By signing and sending this application you are agreeing to abide by all rules and regulations we have here at The H.O.W. Center including daily meetings, a commitment to complete abstinence and continued sobriety and financial independence.
AgreeDo Not Agree