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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 a. name of spouse or ex-spouse b. Their phone #. c. If married Tell us a little about the situation: _____________________________________________________________ _________________________________________ 5.
Legal Status: Parole
Probation
Supervised
Unsupervised 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? Yes No b. Did you complete the program? Yes No c. Was the program successful for you? Yes No 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? Yes No a. What kinds of medication are you currently taking? b. What is the dosage and how often do you take each medication? 9. Why are you prescribed medication? 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 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 a. Name and Place of Church: b. Pastor’s Name: 13. Employment: a. Do you have employment? Yes No b. Where? c. Do you have any prospects? Yes No 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? Yes No b. Are you allowed to have a checking or savings? Yes No c. Do you need assistance opening one? Yes No d. Have you ever been convicted of writing bad checks? Yes No
16. Relationships: a. Are you dating? Yes No b. Are you in a committed “romantic” relationship? Yes No c. With whom? How Long? d. Their phone # e. Do you feel it’s a healthy relationship? Yes No 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? Yes No 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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