Date
*
/
Month
/
Day
Year
Name
*
First Name
Last Name
Age
*
Location
*
DOB
*
/
Month
/
Day
Year
SSN
*
Contact number
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email address
*
Emergency contact
*
Program to which you are applying:
*
Residential
Community
Emergency Response
Self-referral?
*
Yes
No
Referring agency name and number
*
Are you married or partnered?
*
Do you have children?
*
Yes
No
Ages of children
Custody arrangements
Are you pregnant?
*
Yes
No
Unsure
How many months?
Number of years in addiction
*
Chemical preference
*
Length of sobriety
*
Clean time, if any
*
Number of years of trafficking/sexual exploitation
*
Sexual exploitation history (i.e. streets, motels, areas of town)
*
Sexual abuse history
*
Domestic violence history
*
Mental health diagnoses, if any
*
Are you in therapy?
*
Yes
No
Therapist's name
Physical disabilities/chronic, ongoing conditions
*
Medications
*
Suicide attempts
*
Inpatient alcohol and drug (A&D) treatments, intensive outpatient treatments (IOP), and/or recovery programs (NA, AA, etc.)
*
Inpatient psychiatric hospitalizations (including dates)
*
Medical Insurance
*
Medical Provider
*
Arrest record
*
Felonies
*
Pending cases
*
Are you on probation?
*
Yes
No
County
Probation Officer's Name
Probation Officer's Phone Number
Format: (000) 000-0000.
Current family relationships
*
Other important current relationships
*
Education
*
Name of individual completing intake
*
Relationship to candidate
*
Signature
*
Date
*
/
Month
/
Day
Year
Date
WBF Entrance Support Request
Last Revision: 9-14-24
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