• Intake Assessment Application

    Intake Assessment Application

  • Date:*
     / /
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Drivers License?*
  • Marital Status:*
  • Education Level:*
  • Are you a veteran?*
  • Are you pregnant?*

  • Medical Information

  • Do you have allergies?*
  • Are you currently on medication?*
  • Have you had any surgeries?*

  • Mental Health Information

  • Are you suicidal?*
  • Are you homicidal?*
  • Have you attempted suicide?*
  • Have you attended any treatment programs in the last year?*

  • History 

  • Last date of substance abuse:*
     / /

  • Employment History

  • Legal

  • Are you directed by the court for services?*
  • Have you ever been arrested, other than for traffic offenses?*
  • Are you presently on parole or probation?*

  • Personal

  • Do you attend AA, NA, or any other programs currently?*
  • Are you willing to commit to 8 months here at the House of Hope?*
  • Are you willing to have your income monitored?*

  • Personal Opinion

  • Mercer County House of Hope P.O. Box 636, Celina, OH 45822 MercerHouseofHope.com

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  • Should be Empty: