Non-Reentry Interview Questionnaire
Todays Date
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Month
-
Day
Year
Date
Name
First Name
Last Name
Date of Birth
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Month
-
Day
Year
Date
Gender
DOES APPLICANT HAVE THE FOLLOWING WORK READY DOCUMENTS
VALID ID
SOCIAL SECURITY CARD
DOES APPLICANT HAVE MEDICAID? WHICH ONE
SILVERSUMMIT
ANTHEM
HPN
MOLINA
UNKNOWN
SPECIALTY COURT
PENDING CHARGES
PRIOR FELONIES
ANY PRIOR PROGRAM ATTENDANCE
example, Bristlecone, New Frontier, Ridge House, Etc.
PRIOR LIFE CHANGES RESIDENT?
Yes
No
IF PRIOR LC RESIDENT, WHEN?
Enter year.
HISTORY OF SUBSTANCE USE?
Yes
No
DRUG OF CHOICE
CLEAN/SOBER DATE
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Month
-
Day
Year
Date
HAVE YOU EVER BEEN IN RECOVERY?
Yes
No
WHEN?
MENTAL HEALTH DIAGNOSIS??
Yes
No
DIAGNOSIS
CURRENT MEDICATION
PHYSICAL HEALTH DIAGNOSIS??
Yes
No
DIAGNOSIS
CURRENT MEDICATION
MARTIAL STATUS
# OF CHILDREN (minor or adult?)
VEHICLE? (CURRENT DL, REGISTRATION, & INSURANCE REQUIRED
Employed?
Yes
No
Do you have your entry fees?
Yes
No
DO YOU UNDERSTAND THIS IS A FEE BASED PROGRAM AND YOU ARE REQUIRED TOPAY YOUR FEES
Yes
No
ANTICIPATED INTAKE DATE
/
Month
/
Day
Year
Date
WHY DO YOU WANT TO COME TO LC?
WHAT THREE GOALS DO YOU HOPE TO ACCOMPLISH WHILE AT LIFE CHANGES?
GOAL I
GOAL 2
GOAL 3
Name of Interviewer
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