INITIAL INTERVIEW SHEET
Personal Information
Date
-
Month
-
Day
Year
Date
Full Name (First and Last)
First Name
Last Name
Age
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Place of Living
Family Information
Do you have children?
Yes
No
How many children and ages?
Substance Use Information
Drug of Choice
When was the last time you used?
Medical Information
Current medications you are taking
Medical Conditions (Examples: diabetes, eating disorders, heart conditions, upcoming surgeries, etc.)Do you have any medical conditions or physical limitations that may make it difficult for you to climb to a top bunk or complete daily activities such as cleaning chores or standing for long periods of time? If yes, please explain:
Diagnosis of any Mental Illnesses?
Legal Information
Pending Charges
Upcoming Court Dates
Do you have any Warrants?
Yes
No
Are you on Probation or Parole?
Yes
No
Relationship Status
Marital Status
Single
Married
Divorced
Widowed
If single, are you in a relationship?
Yes
No
Additional Notes
Our mission is to restore hope, transform lives, and build a foundation for a brighter future.
You are not alone. You are welcome here.
❤️
Submit
Should be Empty: