The Well Ministries - Intake Form

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Who is filling out this form today? Please choose the option that best describes you:
I am seeking help myself
I am a family member or friend
I am a judge, agent, or legal representative
I am a caseworker or social worker
Other
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Email* This field is required.Please provide an active contact email address
example@example.com
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Please provide referral contact information below: **if applicable
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Please provide client’s full legal name:
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Please provide client's date of birth. (mm/dd/yyyy):
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Please provide client's contact number for call back purposes.
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What program are you interested enrolling in?
Beauty from Ashes - 6 month primary residential program for women
Sparrow’s Nest Maternity Home - 12 month residential program for pregnant women
Mommy & Me - add on to any women’s program after 90 days
Ashley’s Place - 6 month transitional living for women who have completed 6 months of an approved primary program.
Voice of Hope - 6 month primary program for men
Foundation Ministry - 6 month transitional living for men who have completed 6 months of an approved primary program
Meeting at The Well - 12 step recovery meeting held on Thursday nights
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Please tell us about your current situation (be as detailed as possible so we can best help you). Why are you seeking help? ** Please include if you are coming from another program, the name of the program, and the length of stay
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What is your current living situation? Please provide as much detail as possible so we can best help you.
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Do you feel safe in your current living situation?
Yes
No
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Can you freely leave your current living situation without fear or harm?
Yes
No
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Is there now or has there been anyone following, stalking, or pursuing you in anyway? If yes, please explain.
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Has anyone ever forced, threatened, or pressured you to do something you did not want to do in exchange for money, shelter, food, drugs, or protection?
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Are you currently in active addiction? If yes, please list your history and current drug of choice. Please specify what you will be detoxing from.Please include all substances (prescribed or not) used in the last year).
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Are you pregnant?
Yes
No
Unsure
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If pregnant, please list any information you can provide us about your pregnancy.Ex: how far along are you? have you been seeing an o.b.? would you like to enroll in pregnancy counseling to look over your options?
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Do you have children? Please list children’s names, ages, and the name and relationship of who they will be staying with during your time with us.
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Why do you desire to enter recovery?What is pushing you to enter residential treatment? What are some personal goals you hope to accomplish while you are here?
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Emergency Contacts(Please list names, relationship, & number for each one. At least one immediate family member is required.)
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Do you have your GED or High School Diploma?
YESNO
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Do you have a physical copy of your social security card?
YESNO
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Do you have a physical copy of your birth certificate?
YESNO
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Do you have a physical copy of your ID/DL?
YESNO
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Do you have any current or past medical conditions or diagnosis? Please list any conditions we should be aware of (e.g., diabetes, seizures, asthma, pregnancy complications, etc.)
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Have you recently been hospitalized or had any surgeries?Please explain.
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Do you have any conditions or handicaps that would prevent you from working?(If yes, please ensure you have everything listed in full detail in previous question)
YESNO
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Have you ever been diagnosed with a mental condition? Please include all diagnosis and the year & age you received this diagnosis.
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Are you currently on any prescription medications? If yes, please list all current medications, the dosage, and reason for taking them.
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Do you have any allergies? If yes, please list. (Ex: medications, food, etc)
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Do you have asthma?
YESNO
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Do you use an inhaler?
YESNO
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Do you use nicotine?
YESNO
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Please list any past recovery centers or mental facilities, specify what year you were there and if you completed treatment.Please explain.
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Do you have health insurance or Medicaid?
YESNO
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Do you have any upcoming doctor’s appointments? If yes, please give detail.
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Were you referred by someone? Please explain. (Example: Judge, church, treatment center, friend, CPS, etc.)
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Are you currently involved with any of the following?
Probation/Parole
Drug Court
DHS/CPS
Pending charges
Warrants/fines
My record is completely clean.
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Please explain entire legal status with complete detail. Include charges, arrest dates, court dates, legal supervision/agent contact information (county, name, phone number, email, if you’ve contacted your legal supervision/agent about entering our program), etc
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Have you ever been charged with a sex crime? Are you a registered sex offender? Do you have pending charges related to this subject?
YESNO
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Do you have any upcoming court dates or legal deadlines?
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Please list any final information we need to know.
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Do you agree that you have filled this online form out with complete honesty and integrity?
YESNO
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Please type your full legal name as agreement and ownership of the information within this form.
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