Men's Center Questionnaire Form
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Age
*
Ethnicity
*
Please Select
White
African American/Black
Hispanic/Latino
American Indian
2 or more ethnicities
other
If others, please list:
*
N/A if not applicable
Phone Number
*
Format: (000) 000-0000.
Email
*
N/A if not applicable
How did you about us?
*
How do you think we could help?
*
Where are you From?
*
Do you have friends/family in the area?
*
Yes
No
If Yes, who?
*
N/A if not applicable
What's your drug of choice?
*
When was the last time you used?
*
Back
Next
Have you ever been incarcerated?
*
Yes
No
If Yes, When was your release date and reason for you incarceration?
*
N/A if not applicable
Are you on probation/parole?
*
Yes
No
If Yes, where and reason:
*
N/A if not applicable
Have you ever been arrested or convicted of an aggravated offense?
*
Yes
No
If Yes, please explain:
*
N/A if not applicable
Have you ever been arrested for criminal trespassing?
*
Yes
No
If Yes, please explain:
*
N/A if not applicable
Have you ever had a restraining order against you?
*
Yes
No
If Yes, please explain:
*
N/A if not applicable
Do you have violent tendencies?
*
Yes
No
Are you a registered sex offender?
*
Yes
No
Back
Next
Do You have any mental health issues?
*
Yes
No
Have you ever been diagnosed with or treated for any sort of mental health issues?
*
Yes
No
If Yes, please explain:
*
N/A if not applicable
Have you ever been prescribed medicine for any mental health issues?
*
Yes
No
If Yes, what condition?
*
N/A if not applicable
Are you on medication now?
*
Yes
No
Back
Next
Are you currently seeing a physician,counselor or therapist?
*
Yes
No
If Yes, please explain which one you see and the reason:
*
N/A if not applicable
Do you have a medical/physical condition that requires a doctor's care?
*
Yes
No
If Yes, please explain:
*
N/A if not applicable
Have you ever been on disability for a physical/mental health condition?
*
Yes
No
Do you receive a check for a physical/mental health condition?
*
Yes
No
Do you receive a check of any kind?
*
Yes
No
If Yes, Amount and Reason:
*
N/A if not applicable
Haven Homes is a work therapy program. Are you able to work while participating in the program?
*
Yes
No
Back
Next
Have you ever been at a treatment facility or recovery center and been asked to leave?
*
Yes
No
If Yes, please explain:
*
N/A if not applicable
Do you have a photo I.D.?
*
Yes
No
Please review all rules and guidelines
Are you willing to abide by the rules and guidelines?
*
Yes
No
Are you willing to make a 12 month commitment?
*
Yes
No
a background check will be ran
Signature
Submit
Submit
Should be Empty: