The Well Ministries - Intake Form

1

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

2

Please provide referral contact information below: **if applicable

3

Please provide client’s full legal name:

4

Please provide client's date of birth. (mm/dd/yyyy):

5

Please provide client's contact number for call back purposes.

6

Please provide an updated email.

7

Please provide client's home address.

8

May we contact you?

YESNO

9

Preferred contact method.

Text message

Email

Phone call

Do not contact me

10

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

11

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

12

What is your current living situation? Please provide as much detail as possible so we can best help you.

13

Do you feel safe in your current living situation?

Yes

No

14

Can you freely leave your current living situation without fear or harm?

Yes

No

15

Is there now or has there been anyone following, stalking, or pursuing you in anyway? If yes, please explain.Please provide as much detail as possible so we can best help you.

16

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?Please provide as much detail as possible so we can best help you.

17

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).

18

When was the last time you maintained sobriety? What was the time frame of this sobriety?

19

Are you pregnant?

Yes

No

Unsure

20

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?

21

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.

22

Are you currently employed?If yes, please include company's name, contact information, and if they have been informed of your desire to enter residential recovery? **We will not contact them without your verbal permission.

23

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?

24

Emergency Contacts(Please list names, relationship, & number for each one. At least one immediate family member is required.)

25

Do you have your GED or High School Diploma?

YESNO

26

Do you have a physical copy of your social security card?

YESNO

27

Do you have a physical copy of your birth certificate?

YESNO

28

Do you have a physical copy of your ID/DL?

YESNO

29

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.)

30

Have you recently been hospitalized or had any surgeries?Please explain.

31

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

32

Have you ever been diagnosed with a mental condition? Please include all diagnosis and the year & age you received this diagnosis.

33

Are you currently on any prescription medications? If yes, please list all current medications, the dosage, and reason for taking them.

34

Do you have any allergies? If yes, please list. (Ex: medications, food, etc)

35

Do you have asthma?

YESNO

36

Do you use an inhaler?

YESNO

37

Do you use nicotine?

YESNO

38

Please list any past recovery centers or mental facilities, specify what year you were there and if you completed treatment.Please explain.

39

Do you have health insurance or Medicaid?

YESNO

40

Do you have any upcoming doctor’s appointments? If yes, please give detail.

41

Do you receive any government assistance?

YESNO

42

Were you referred by someone? Please explain. (Example: Judge, church, treatment center, friend, CPS, etc.)

44

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

45

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

46

Do you have any upcoming court dates or legal deadlines?

47

Please list any final information we need to know.

48

Do you agree that you have filled this online form out with complete honesty and integrity?

YESNO

49

Please type your full legal name as agreement and ownership of the information within this form.