Intake Application

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email

example@example.com

Phone Number

Area CodePhone Number

What is the status of your COVID vaccination?*

I am fully vaccinatedI am not vaccinated

How much time has passed since your last arrest and/or conviction? *

How long of a sentence did you serve in jail or prison? (Include multiple time served)

Please describe any achievements or areas of accomplishments while incarcerated (if applicable) *

What is the highest grade completed from K-12?*

How much do you value Money?*

On a scale of 1-5

How much do you value Family?*

On a scale of 1-5

How much do you value Marriage?*

On a scale of 1-5

How much do you value your Job?*

On a scale of 1-5

How much do you value your Safety?*

On a scale of 1-5

How much do you value Livable Wage/Income?*

On a scale of 1-5

How much do you value voting?*

On a scale of 1-5

How much do you value Personal Independence?*

On a scale of 1-5

How much do you value Recovery?*

On a scale of 1-5

How much do you value Education?*

On a scale of 1-5

How much do you value Career Advancement?*

On a scale of 1-5

How much do you value Love?*

On a scale of 1-5

How much do you value Health?*

On a scale of 1-5

How much do you value Freedom?*

On a scale of 1-5

How much do you value Life Insurance?*

On a scale of 1-5

How much do you value Health Insurance?*

On a scale of 1-5

How much do you value Financial Security?*

On a scale of 1-5

How much do you value Religion?*

On a scale of 1-5

How much do you value Housing?*

On a scale of 1-5

How much do you value Justice?*

On a scale of 1-5

How much do you value Children?*

On a scale of 1-5

Type a question

What is your dream?*

What would you describe as the greatest accomplishment of your life?*

I'm not the problem. It doesn't make much sense for me to consider changing.*

Choose the response that best describes how much you agree or disagree with each statement.

I am finally doing some work on my problem.*

I've been thinking that I might want to change something about myself.*

At times my problem is difficult, but I'm working on it.*

Trying to change is pretty much a waste of time for me because the problem doesn't have to do with me.*

I'm hoping that I will be able to understand myself better.*

I guess I have faults, but there's nothing that I really need to change.*

I have a problem and I really think I should work on it.*

I'm not following through with what I had already changed as well as I had hoped, and I want to prevent a relapse of the problem.*

I am really working hard to change.*

Even though I'm not always successful in changing, I am at least working on my problem.*

I thought once I had resolved the problem I would be free of it, but sometimes I still find myself struggling with it.*

Maybe someone or something will be able to help me.*

I wish I had more ideas on how to solve my problem.*

I may need a boost right now to help me maintain the changes I've already made.*

Name

First NameLast Name

I hope that someone will have some good advice for me.*

Anyone can talk about changing; I'm actually doing something about it.*

I'm struggling to prevent myself from having a relapse of my problem.*

It is frustrating, but I feel I might be having a recurrence of a problem I thought I had resolved.*

I am actively working on my problem.*

After all I had done to try and change my problem, every now and then it comes back to haunt me. *

I have worries but so does the next guy. Why spend time thinking about them?*

Texting/SMS*