Potential Resident Prescreen Form
Share your contact, background, and recovery goals so we can review eligibility and guide next steps.
⚠️ If you are in crisis, feeling suicidal, or thinking about harming yourself, please call 911 or dial 988 for immediate assistance. You are not alone, and help is available 24/7.
Contact Information
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Current City
Current State
Emergency Contact Name
Emergency Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Program Interest
How did you hear about Midway Recovery Systems?
Referral/Provider
Probation or Court
Hospital/Detox/Treatment Program
Friend or Family
Community Organization/Church
Social Media/Internet
Other
If "Other," please specify
Are you seeking residential recovery support at this time?
*
Yes
No
Background Information
Are you currently using or have you recently used alcohol or substances?
*
Yes
No
If yes, please describe.
Have you ever participated in treatment or recovery housing before?
Yes
No
If yes, where?
Do you have any current legal requirements (probation, court mandate, etc.)?
Yes
No
If yes, please explain.
Health & Wellness
Are you currently under medical or mental health care?
Yes
No
If yes, please list any conditions or medications.
Have you been advised to complete a detox program before entering recovery housing?
Yes
No
A detox referral may be recommended to ensure a safe and comfortable transition. This does not disqualify you from the program.
Employment & Financial Support
Are you currently employed?
Yes
No
Do you have financial support or the ability to contribute toward program fees?
Yes
No
Unsure
Some residents may qualify for financial assistance or a scholarship, based on individual circumstances.
Goals
What are your goals for recovery and personal growth?
Next Steps
A Midway Recovery Systems team member will contact you within 24–48 hours to review your prescreen and discuss the next step toward admission.
Ready to Begin?
Submit this form or call us directly at (770) 227-8975 to complete your prescreen assessment.
We’re here to help — no pressure, no judgment, just support.
Submit Application
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