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Entrance Questionnaire Please fill out this form completely. If you need additional space please use the back of this form. All of your answers and information will be kept confidential. 1.Name:___________________________________________________ 2. Date of Birth: ___________ - ____________ - _____________ 3. Social Security #:_____________ - ____________ - ______________ 4. Marital Status: Married, Single, Divorced, Widowed. (Circle one). a. name of spouse or ex-spouse________________________________ b. Their phone #. ______________________________ c. If married Tell us a little about the situation: _____________________________________________________________ _________________________________________ 5.
Legal Status: Parole or Probation, Supervised or Unsupervised.
(Circle one) 6. List Convictions: ______________________________________________________________ a. Place and Time served:_________________________________________ b. Name of Probation/Parole Officer: _________________________________________ c. What county are you serving Probation/Parole? _______________________________ e. If currently incarcerated or are in another program or facility, when is your expected release date:___________ 7. Past drug or alcohol use: ________________________________________________________ _________________________________________ a. Have you ever been in a drug or alcohol treatment program? ___________ b. Did you complete the program? ____________ c. Was the program successful for you? _____________ d. Why or why not? ____________________________________________________________ ___________________________________________________________________________ _____________________________________________________________________________ e. If you were in a program before, what do you feel is different about you or your circumstances now?___________________________________________________________________________ ________________________________________________________________________________ _______________________________________________________________________________ _____________________________________________________ 8. Are you taking prescription medication___________________ 9. Why are you prescribed medication? (Explain purpose) ____________________________________________________________ ____________________________________________________________ a. When was your last Doctors visit for this medication? _________________________ b. When is your next Doctors visit for this medication? _________________________ 10. Have you ever been admitted to a mental facility or a mental treatment program? a. Yes or No? _______________ b. Where and how long? ___________________________________________________ 11. Religion. a. What is your religious background? _________________________________________ e. Do you see God as a part of your life? If yes please explain ______________________ ________________________________________________________________________ ________________________________________________________________________
12. Church attendance: Weekly, Holidays only, as a child, never. (Circle one) a. Name and Place of Church: _____________________________________ b. Pastor’s Name: _______________________________________________ 13. Employment: a. Do you have employment? __________________ b. Where? __________________________________ (If No) c. Do you have any prospects? __________________ d. Where? __________________________________ 14. Financial information: (list all monthly payments and amounts). a. Child support $ _______________ b. Alimony $ ___________________ c. Court/restitution $ ______________ d. Credit cards $ _________________ e. Bank loans $ ___________________ f. Personal loans $ ________________ g. misc $_______________ 15. Banking Information: a. Do you have a checking or savings account? _______________ (If No) b. Are you allowed to have a checking or savings? ____________ (If Yes) c. Do you need assistance opening one? ______________ d. Have you ever been convicted of writing bad checks? _________
16. Relationships: a. Are you dating? _____________ b. Are you in a committed “romantic” relationship? _____________ (If Yes) c. With whom? _____________________________ How Long? ____________ d. Their phone #. ___________________________ e. Do you feel it’s a healthy relationship? ______________ f. Why? ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ 17. Emergency contacts: (This is for emergency use only). a. Name: __________________________ Relationship: ________________ Address: _______________________ City/State. _____________________ Zip: __________ Phone #:(____) ________ - ________ Cell #: (____) _______- _______ b. Name: __________________________ Relationship: ________________ Address: _______________________ City/State. _____________________ Zip: _________________Phone #: (____) ________ - _______ Cell #: (___) ________ - ________ c. Name: __________________________ Relationship: _______________ Address: ______________________ City/State. ______________________ Zip: ______ Phone #: (______) ________ - ___________ Cell #: (______) ________ - __________
18. What caused you to need the Lighthouse program?
19. Do you feel your life is unmanageable right now? If yes, explain!
20. List some things you’re hoping to get out of this program
19. List some short term goals for your life (the next six months).
20. List three mid-term goals for your life: (next 1-3 years).
21. Any other information that you think might be helpful so that we can serve you better:
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