THH Intake Form
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  • Treasure House of Hope Intake Form

  • Today's Date*
     - -
  • Date of Birth*
     - -
  •  -
  • Marital Status*
  • Do you have children?*
  • Do you have custody of your child(ren)?*

  • Disclaimer*

    If you have not taken a COVID-19 test or have tested positive, you will not be accepted until you have negative results.

  • Have you been tested for COVID-19?
  • What were the results?

  • Are you on parole or probation?*
  • Can you read, write and understand English?*
  • Are you willing to participate in any training programs?*
  • Do you have any physical or mental health conditions?*
  • Do you smoke cigarettes or use tobacco products?*
  • Are you willing to call the Tobacco Quit Line for help to stop smoking or using tobacco?*
  • Do you take any medications?*
  • Have you ever been in counseling?*
  • Have you ever had an eating disorder?*
  • (WOMEN) Are you pregnant?*
  • Do you have a disability?*
  • Do you have any allergies?*
  • Do you have any health or dental concerns at this time?*
  • Check all that apply to you*

  • Have you ever been convicted of a crime?*
  • Have you ever been sentenced to county jail or prison?*
  • Do you have any outstanding warrants?*
  • Do you owe fines?*
  • Do you have a lawyer or public defender?*
  • Are you taking any classes for crimes you have committed?*
  • Have drugs and/or alcohol ever been a problem for you?*
  • Have you ever been to detox?*
  • Have you ever been in treatment for drug/alcohol abuse?*
  • Are you willing to take random urinalysis and/or breathalyzers?*
  • Have you been checked for HIV or AIDS in the last three months?*

  • Comprehension of Program

  • Please read the following statements. By checking the box next to each, you are agreeing to each statement.*

  • Interested Applicants: Please note - we will review all submitted Intake Forms. We will contact you IF YOU MEET the criteria

  • Should be Empty: