DWC Intake Application
Fill in the form below as accurately as possible indicating your suitability for our program.
Do you understand that the DWC Recovery Program is a 2 year commitment?
Yes
No
Name
*
First Name
Last Name
Birth Date
Please select a month
January
February
March
April
May
June
July
August
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December
Month
Please select a day
1
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Day
Please select a year
2024
2023
2022
2021
2020
2019
2018
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2015
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2012
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Year
Age
Contact Phone Number
Email
How were you referred to DWC?
Treatment Referral
Judicial Referral
Personal Referral
I’ve Been in DWC Before
Facebook
Luncheon
Other
Are you from Amarillo, Texas?
Yes
No
Do you have a valid ID or DL?
Yes
No
Do you have a Social Security Card?
Yes
No
Do you have a birth certificate?
Yes
No
Drug of choice
Please list all of the drugs that you use regularly.
Check all of the drugs that you have ever used:
Alcohol
Marijuana
Cocaine
Crack Cocaine
Methamphetimines
Pain Killers/Opiods
Fentanyl
Acid
Mushrooms
K2
Delta
Barbituates
Benzos
Ecstacy
Mollys
Heroin
Methadone
Suboxone
Codeine
IV Drugs
Do you believe you are an addict or alcoholic?
Yes
No
Are you currently in treatment/rehab?
Yes
No
If yes, where?
Please Select
Cenikor
Serenity
Grace Manor
Other
If yes, what is your projected release date?
-
Month
-
Day
Year
Are you attending AA/NA?
Yes
No
Are you currently using a sponsor?
Yes
No
Are you working the steps?
Yes
No
If yes, what step are you on?
Please Select
Step 1
Step 2
Step 3
Step 4
Step 5
Step 6
Step 7
Step 8
Step 9
Step 10
Step 11
Step 12
Is there family history of addiction? (parents, grandparents, siblings)
Yes
No
Have you had the Covid 19 vaccination?
Yes
No
Have you had the Flu vaccination this year?
Yes
No
Do you have private health insurance or Medicaid?
Yes
No
Please list all medications you are currently taking.
Please list all medications you are not taking but feel you should be.
Please list any physical health diagnosis.
Are you able to work 29-32 hours per week?
Yes
No
Please list any mental health diagnosis.
Have you ever been hospitalized for mental health?
Yes
No
Have you ever attempted suicide?
Yes
No
Are you on probation or parole?
Yes
No
Do you have a car?
Yes
No
If yes, is everything up to date? (tags, insurance, inspection)
Yes
No
Do you currently have income?
Yes
No
Are you currently in a relationship?
Yes
No
Marital Status
Single
Divorced
Married
Separated
Education Status
GED
High School Diploma
Some College
College Degree
Why do you want to come into the DWC Recovery Program?
Are you pregnant?
Yes
No
Do you have children?
Yes
No
If yes, how many children do you have?
Please provide the names and ages of your children.
Do you have custody of your children?
Yes
No
Are your children currently placed elsewhere?
Yes
No
Are you interested in reunification?
Yes
No
Do you have an open CPS case?
Yes
No
What makes you a good candidate to be in our program?
Submit Application
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