Name
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First Name
Last Name
Date
Email
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Phone
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Message
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Where did you sleep last night?
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Why do you need/want our program?
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Have you ever been:
If yes, why? Please be specific.
What is your marital/relationship status?
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Do you have any children?
What is your highest level of education?
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Do you have a drivers License? (If not, why not?)
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Employment Information (current and past job skills. Are you willing/able to work 40 hours a week?)
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What type of work do you like to do?
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Military History
Please provide any Mental Health Information (diagnoses, outpatient treatment dates and locations)
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Have you ever attempted or contemplated committing suicide?
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Substance abuse information (current/past, type of substance, length of use, treatment info-inpatient or outpatient, are you willing to be connected to services if not already?)
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What role did substance use or compulsive habits play in your incarceration or periods of bad experiences in your life?
Do you use tobacco? If yes, how many packs/cans per day?
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Physical Health Information: (diagnoses/history, needs, chronic conditions, insurance, medical provider. Do you require special accommodations? If yes, what are they?
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List all current medications (If possible, include dosage and frequency taken).
What are your thoughts about participating in mandatory chores or student training programs?
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Do you owe child support? If so, how much and are you currently paying.
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Have you ever been arrested? (If so, when and for what)
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Have you ever been convicted of a felony? (If so, what was the crime, sentence and place served?)
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If currently incarcerated, when is your expected EOS (end of sentence) date?
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Are you currently on probation? (If so, what is the probation officer’s name, what are the requirements and when is the expected termination date?)
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Are you required under the laws of a state or the Federal government to register as a sexual offender or sexual predator? THIS IS NOT a disqualifier
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Other agency involvement (agency and case worker’s names and numbers, services provided in the past year, any problems or difficulties encountered)
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Behavioral Information: Regardless of fault, have you ever been removed or banned from any place?
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Have you ever had a restraining order filed against you? If yes, why?
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What are your hobbies, activities, interests
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What do you want to improve in your life? What do you want to eliminate in your life?
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Future Plans Do you have a spiritual support system? If yes, what? What are your future plans? Where would you like to be living one year from now?
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What are you thoughts about attending/participating in mandatory Christian church services and Bible studies?
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