Entry Assessment Form
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Are you homeless
*
Yes
No
Email
*
example@example.com
Date of Birth
*
Gender
*
Please Select
Male
Female
Social Security Number
*
Do you have a form of picture ID? If so, what type?
*
Upload Photo ID
Browse Files
Drag and drop files here
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Contact Person Information
Please provide information for 2 individuals we can contact as references. These individuals should have direct knowledge of your current struggle and be willing to serve as a contact person for you while you are in the program.
Contact Person #1 Name:
*
First Name
Last Name
How do you know this person?
*
Phone Number
*
Please enter a valid phone number.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact Person #2 Name
*
First Name
Last Name
How do you know this person?
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
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History/Background Information
Do you have any outstanding warrants
*
Yes
No
Is Yes, where?
*
Do you have pending court dates?
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Yes
No
If Yes, when, where and for what?
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Are you on probation?
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Yes
No
If Yes, who is your probation officer? Location?
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Length of probation?
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List the offense(s): (If NONE type N/A in box)
*
Are you currently incarcerated?
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Yes
No
If Yes, where?
*
Expected Release Date
*
-
Month
-
Day
Year
Date
Are you a registered sex offender?
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Yes
No
List all priors you have received: (If NONE type N/A in box)
*
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Medical/Health Information
Medical conditions, allergies, disabilities?
*
Have you been tested for any STDS? (HIV, Syphilis, Herpes, Chlamydia, Gonorrhea)
*
If yes, what were the results?
*
Do you have Hepatitis C?
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Yes
No
Have you had a positive TB test?
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Yes
No
Do you have health issues that requires medical attention? If so what? (You will need a Doctor's clearance if so)
*
Do you need a Pap Smear or Mammogram? (If so, this must been completed before entering the program)
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Yes
No
Do you need glasses? (If so, have eyes checked and glasses or contacts purchased before entering the program)
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Yes
No
Do you have dental needs?
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Yes
No
Are you or could you possibly be pregnant?
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Yes
No
If yes, how far along?
*
Do you smoke cigarettes, dip or vape?
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Yes
No
If yes, are you willing to stop? (We are a NICOTINE FREE facility)
*
Yes
No
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Mental Health
Have you ever had a mental health evaluation?
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Yes
No
If yes, provide doctor's name and diagnosis?
Were you diagnosed as a child, or before you began drugs/alcohol?
Have you ever delt with any eating disorders? (Anorexia or bilimia)
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Yes
No
Have you ever engaged in self-mutilation? (Cutting, burning, etc.)
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Yes
No
Have you ever been so angry that you harmed yourself or others?
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Yes
No
Have you ever been hospitalized for mental health issues?
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Yes
No
If yes, please list when and where?
Do you have a family history of mental health issues?
*
Yes
No
Have you ever had thoughts of or attempted to commit suicide?
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Yes
No
If yes, how long ago and what happened? (*If you aren't comfortable writing this you don't have to. You can speak to us in person regarding this.
If yes, do you still have these thoughts?
Yes
No
Have you ever experienced abuse, verbal, sexual, physical or mental?
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Yes
No
If yes, are you still in contact with the person that abused you?
Yes
No
Have you ever had panic attacks?
*
Yes
No
Please list below all medications you are currently taking, even over the counter medications: (Medication - Dosage/Frequency - Doctor who prescribed it) If NONE type N/A in box
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Substance Abuse History
What is you substance of choice?
*
At what age did you begin drinking alcohol?
*
At what age did you begin using drugs?
*
When is the last time you used? What did you use and how much?
*
Have you ever been in a program before? When and where?
*
Did you finish the program? If no, what was the reason for termination?
*
Your longest amount of time clean and sober?
*
Please select below the drugs you have used:
*
Alcohol
Amphetamines (Adderral, Ritalin, etc.)
Benzos (Valium, Xanax, etc)
Cocaine
Hallucinogens
Heroin
Kratom
Lean/Liquid Codeine
Marijuana
Delta 8
MDMA (Ecstasy, Molly, etc.)
Methadone
Suboxone
Methamphetamines (Meth, Ice, Crank, etc.)
Opiates/Painkillers
PCP (Angel dust)
Synthetic Marijuana (Spice)
Inhalants
Tobacco
Please select all ways you used drugs:
*
Eat
Snort
Smoke
IV (Shoot up)
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Family/Personal Relationships
Are you:
*
Married
Divorced
Separated
Widowed
Single
If you are married spouse's name and length of time you have been married?
Do you have an on-going relationship that would interfere with your focus on your recovery?
*
Yes
No
If so, please explain that relationship:
Do you have children?
*
Yes
No
Below please list each child's NAME - AGE - BOY/GIRL - CUSTODY - RELATIONSHIP
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RULES AND REGULATIONS
Are you willing to abide by The Mercy Seat's Rules and REGULATIONS? And adhere to the dress code?
*
Yes
No
Are you willing to commit to a full day of classes and work therapy?
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Yes
No
Participation in this program requires you to be able to perform physical duties such as: housekeeping, yard work and volunteering. These physical requirements include standing for long periods of time, walking, squatting, bending, climbing, sitting and lifting (up to 15 pounds). Can you perform these functions?
*
Yes
No
If no, why not?
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What do you hope to get out of this program?
*
Describe your religious background/beliefs:
*
By signing the space below, you are certifying that all information is correct and that you are the person completing this application. Completion of this application does not confirm your acceptance into The Mercy Seat Women's Recovery Program. When you press the submit button, you will receive an email confirmation that your application was received. Please print for your records and retain as verification of your application.
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