Pre Screen Application

Complete this application and you will be contacted to schedule a meeting or a phone call.

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Referring Agency

Agency Telephone

Your Name

Age

Personal Telephone

Coming From

If other, please specifiy

Placement needed by

Are you employed?

If yes, place of employment

Additional sources of income

If other, please specifiy

Have you ever been diagnosed with a mental illness or been prescribed medication for mental illness?

If yes, what was the diagnosis and when?

Do you take any medications?

If yes, which ones?

Do you have any other medical conditions?

If yes, which ones?

Have you been tested for COVID-19 / Coronavirus?

If yes, on what date?

What is your primary drug of choice?

What is your secondary drug of choice?

How many days have you been sober?

When was the last time you used drugs?

What drug did you use?

Are you in treatment?

Do you have minor aged children?

Are you a registered sex offender?

This form is submitted securely.