HEALING AND RESTORING WOMEN FROM ADDICTION
Personal Information
Name
*
First Name
Last Name
Middle Name
Nickname
Phone Number
*
Format: (000) 000-0000.
Email Address
example@example.com
Date of Birth
*
/
Month
/
Day
Year
Date
Age
*
Place of Birth
Today's Date
/
Month
/
Day
Year
Date
Address
City
State
Zip Code
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Emergency Contact Information
Name
*
First Name
Last Name
Relationship
*
Phone Number
*
Format: (000) 000-0000.
Address
City
State
Zip Code
Are your parents still leaving?
*
Both alive
Father only
Mother only
Both deceased
Father's Name
First Name
Last Name
Mother's Name
First Name
Last Name
Address
City
State
Zip Code
Are your parents separated or divorced?
*
Yes
No
Do you have siblings?
*
Yes
No
How many brothers?
*
How many sisters?
*
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Marital Status/Children
Marital Status
*
Married
Single
Separated
Divorced
Widowed
Husband's name
First Name
Last Name
Reasons for Divorce or Separation
*
Do you have any children?
*
Yes
No
How many children?
Names of children and ages
Do you have custody of your children?
*
Yes
No
Who does have custody of your children?
*
First Name
Last Name
Are you subject to any alimony/child support payments?
*
Yes
No
How much?
*
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Education
Did you graduate from high school?
*
Yes
No
Which high school?
*
Did you attend college?
*
Yes
No
What was your major and degree earned?
*
Did you attend trade school?
*
Yes
No
Which trade?
*
Did you complete trade school?
*
Yes
No
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Work History
Are you currently employed?
*
Yes
No
Current Occupation
Years of Experience in Current Occupation
Company 1
Company 2
Company 3
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Military Experience
Are you a veteran?
*
Yes
No
Branch of Service
Highest Rank
Years in Service
Discharge Date
/
Month
/
Day
Year
Date
Discharge Type
Please Select
Honorable Discharge
General Discharge (Under Honorable Conditions)
General Discharge (Under Other than Honorable Conditions)
Bad Conduct Discharge
Dishonorable Discharge
Please explain reason for discharge
Were you ever court-martialed?
Yes
No
If yes please explain reason for courtmartial
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Medical Information
What is the state of your health?
*
Excellent
Good
Fair
Poor
Declining
Height
*
Ex: 5'10''
Weight
*
Ex: 190lbs
Usual Weight
*
Ex: 195lbs
Any recent weight changes?
*
Yes
No
List all major illness and/or surgeries you had or currently have
Have you ever had a venereal disease?
*
Yes
No
What disease?
*
When did you contract the disease?
*
When were you last tested for HIV?
*
When were you last tested for Hepatitis C?
*
When were you last tested for TB?
*
Do you smoke or chew any form of tobacco (e.g., cigarettes, dip, etc.)?
*
Yes
No
Are you currently taking any prescription or over-the-counter medication?
*
Yes
No
Please list any medication you are currently taking
*
Have you ever suffered from depression?
*
Yes
No
Please describe
*
Have you ever been treated for any psychiatric illness?
*
Yes
No
Please describe conditions and treatment
*
Have you ever considered suicide?
*
Yes
No
When?
*
Have you ever attempted suicide?
*
Yes
No
When and why?
*
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Alcohol/Drug Use History
How many rehabilitation centers have you attended?
*
None
One
Two
Three +
Please list any rehabilitation centers you have attended
*
What is/are your drug(s) of choice?
*
At what age was your first drinking/drugging experience?
*
How has your drinking/drugging pattern changed?
*
What is your longest period of sobriety in the past two years?
*
When did you last drink or get high?
*
What did you drink/use?
*
Is there any other information about your drug or alcohol use you wish to share?
*
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Criminal History
Number of times arrested?
*
None
One
Two
Three +
Please list the charges
*
have you ever been charged with any sexual crime?
*
Yes
No
Please list the charges
*
Are there any charges pending against you at this time?
*
Yes
No
Please list your court date
*
/
Month
/
Day
Year
Date
Are you currently on probation/parole?
*
Yes
No
For how long?
*
Name of probation/parole officer
*
Phone Number of probation/parole officer
*
Format: (000) 000-0000.
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Spiritual Background
What is your church affiliation?
*
Do you have a personal relationship with Jesus Christ?
*
Yes
No
Not Sure
Briefly describe your testimony and your walk with Christ since that time
*
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Healing & Goal Setting
Have you experienced any form of abuse, including sexual, physical, or emotional/mental abuse?
What specific areas of healing are you hoping to gain through the program?
What goals are you hoping to achieve?
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