Pre-Entry Registration Form
Participant Details:
Full Name
*
First Name
Last Name
Address
*
*Must be last known residential address, it cannot be a treatment center.
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of birth
-
Month
-
Day
Year
Date
Phone Number
*
Format: (000) 000-0000.
E-mail
example@example.com
Race/Ethnicity
*
Black/African-American
White/Caucasian
Asian
Native Hawaiian/Pacific Islander
Hispanic/Latino
Native American
Two or More
Other
Gender
*
Female
Male
Non-Binary
Transgender
Other
Marital Status
*
Single
Married
Divorced
Widow
Separated
Prefer Not to Say
Family & Dependents
*
None
1-3
3-5
5+
Employment
*
Unemployed, but able to work full-time
Part-time
Full-time
Contract or Temporary
Retired
Unable to Work
Have you ever been in treatment? If YES, please list agency or program and date of last treatment.
*
Have you ever attended any mutual aid groups such as AA or NA? If YES, please list which groups you have attended and date of last attendance.
*
Have you ever lived in a recovery residence before? If YES, please list the name of the facility and why you left.
*
Are you on any Medication- Assisted Treatment (MAT)?
*
Yes
No
Date of last drug use
*
Date of last alcohol use
*
Have you ever been charged with any?
*
Violent Crimes
Criminal Sexual Crimes
Arson Crimes
I have not been charged with any violent, arson, or criminal sexual crimes
Are you on Parole?
*
Yes
No
Are you on Probation?
*
Yes
No
Why do you believe sober living at West Haven House is the right place for you?
*
Submit
Should be Empty: