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