DWC Screening Application
  • DWC Screening Application

    DWC Screening Application

    Fill in the form below as accurately as possible indicating your suitability for our program.
  • Format: (000) 000-0000.
  • If you have used in the last 30 days, are you willing to go to a treatment facility?*
  • How were you referred to DWC?*
  • Are you from Amarillo, Texas?*
  • Do you have a valid ID or DL?*
  • Do you have a Social Security Card?*
  • Do you have a birth certificate?*
  • Check ALL of the drugs that you have ever used:*
  • Check only your main drug of choice:*
  • Do you believe you are an addict or alcoholic?*
  • Are you currently in treatment/rehab?*
  • If yes, what is your projected release date?
     - -
  • Are you attending AA/NA?*
  • Are you currently using a sponsor?*
  • Are you working the steps?*
  • Is there family history of addiction? (parents, grandparents, siblings)*
  • Have you had the Covid 19 vaccination?
  • Have you had the Flu vaccination this year?
  • Do you have private health insurance or Medicaid?*
  • Please check all physical health diagnosis:
  • Are you physically able to work 29-32 hours per week?*
  • Please check all mental health diagnosis:
  • Have you ever been hospitalized for mental health?*
  • Have you ever attempted suicide?*
  • Are you on probation or parole?*
  • Do you have a car?*
  • If yes, is everything up to date? (tags, insurance, inspection)*
  • Do you currently have income?*
  • Are you currently in a relationship?*
  • Marital Status*
  • Are you pregnant?*
  • Do you have children?*
  • Do you have custody of your children?*
  • Do you have an open CPS case?*
  • Are your children currently placed elsewhere?*
  • Are you interested in reunification?*
  • Education Status*
  • Are you willing to commit to a 2-year program?
  • Should be Empty: