Screening Form

Screening Form

Please fill out this form to the best of your ability. Please be truthful this form does not automatically make you eligible or ineligible for the program. This form is for screening purposes only to determine if you are eligible to enter the program. All information recorded below is confidential information and will not be shared with any other entity. The program does not discriminate based on age, race, sex, or political association.
Name*

First NameLast Name
MaleFemale
Social Security Number*
Date of Birth*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
Please answer the following questions:
YesNo
If yes, when was the last time you had a drink/drug?
YesNo
YesNo
What is your religious belief? Explain…..*
YesNo
If yes, give some details:
What felonies or convictions are on your record?*
YesNo
YesNo
YesNo
Family Questions
YesNo
YesNo
YesNo
YesNo
YesNo
If yes, how many? What are their ages?
YesNo
YesNo
If yes, how many? Are they long-term or short-term?
YesNo
Medical
YesNo
YesNo
YesNo
If yes, please state which medications:
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
If so, what are they:*
History of illness or accidents:*
YesNo
If so, what is/are the reason(s)?
List all medications you are currently taking, the dosage, the reason you are taking them, and the prescribing doctor(s):*
YesNo
Additional comments regarding your health:
Employment / Legal
YesNo
What is your source of income?*
YesNo
YesNo
YesNo
For how long?
Probation Officer
Judge
Court
YesNo
YesNo
YesNo
YesNo
YesNo
How would you describe your current circumstances/situation?*
Why do you believe Under His Construction will help you?*
Do you have any other comments you would like to make? If so, please do so below:
Agreements
YesNo
YesNo
YesNo
I agree that all the information provided by me has been answered truthfully and to the best of my ability. I understand that the information provided is for the sole purpose to determine my eligibility and to best help the Recovery Program determine the type of services I will need. Please use your mouse or finger to sign below.
Signature
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Screening Form

Please answer the following questions:

Family Questions

Medical

Employment / Legal

Agreements