Pre-Resident Screening Form

Fields marked with asterisk (*) are required:











    *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

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