DWC Intake Application

DWC Intake Application

Fill in the form below as accurately as possible indicating your suitability for our program.
Name*

First NameLast Name
Contact Phone Number*
Email*
Last Date of Use*

MonthDayYear
If you have used in the last 30 days, are you willing to go to a treatment facility?*

YesNoNot applicable
Birth Date*

MonthDayYear
Age*
How were you referred to DWC?*

Treatment ReferralJudicial ReferralPersonal ReferralI’ve Been in DWC BeforeFacebookLuncheonOther
Name of Personal Referral

First NameLast Name
Are you from Amarillo, Texas?*

YesNo
Do you have a valid ID or DL?*

YesNo
Do you have a Social Security Card?*

YesNo
Do you have a birth certificate?*

YesNo
Drug of choice*
Please list all of the drugs that you use regularly.
Check all of the drugs that you have ever used:*

AlcoholMarijuanaCocaineCrack CocaineMethamphetiminesPain Killers/OpiodsFentanylAcidMushroomsK2Delta 8BarbituatesBenzosEcstacyMollysHeroinMethadoneSuboxoneCodeineIV DrugsKratomZaZa
What age did you start using any drug at all? *
Do you believe you are an addict or alcoholic?*

YesNo
Are you currently in treatment/rehab?*

YesNo
If yes, where?
If yes, what is your projected release date?

MonthDayYear
Are you attending AA/NA?*

YesNo
Are you currently using a sponsor?*

YesNo
Are you working the steps?*

YesNo
If yes, what step are you on?
Is there family history of addiction? (parents, grandparents, siblings)*

YesNo
Have you had the Covid 19 vaccination?

YesNo
Have you had the Flu vaccination this year?

YesNo
Do you have private health insurance or Medicaid?*

YesNo
Please list any physical health diagnosis.*
Are you able to work 29-32 hours per week?*

YesNo
Please list any mental health diagnosis.*
Please list all medications you are currently taking.*
Please list all medications you are not taking but feel you should be.*
Have you ever been hospitalized for mental health?*

YesNo
Have you ever attempted suicide?*

YesNo
Are you on probation or parole?*

YesNo
Do you have a car?*

YesNo
If yes, is everything up to date? (tags, insurance, inspection)*

YesNoNot Applicable
Do you currently have income?*

YesNo
Are you currently in a relationship?*

YesNo
Marital Status*

SingleDivorcedMarriedSeparated
Are you pregnant?*

YesNo
Do you have children?*

YesNo
If yes, how many children do you have?
Please provide the names and ages of your children.
Do you have custody of your children?

YesNo
Do you have an open CPS case?*

YesNo
Are your children currently placed elsewhere?*

NoYes
Are you interested in reunification?*

YesNoNot Applicable
Education Status*

GEDHigh School DiplomaSome CollegeCollege Degree
Why do you want to come into the DWC Recovery Program?*
What makes you a good candidate to be in our program?*
Should be Empty: