Admission Questionnaire
Please answer all the questions below to be considered for the Doorway Recovery Program. Please remember this is a men's only drug and alcohol residential rehabilitation program, we do not offer shelter unless you have an addiction problem and commit to the 4-5 month program.
Applicants Name
First Name
Middle Name
Last Name
Name of person filling out form (if different from above)
First Name
Last Name
Phone Number
Please enter a valid phone number for us to contact you.
Format: (000) 000-0000.
Email Address
Please enter a valid email address you can be reached at.
Today's Date
-
Month
-
Day
Year
Date
Date of Birth
-
Month
-
Day
Year
Date
Has the applicant ever been a resident at Open Door Mission?
Yes
No
If yes, when was the applicant a resident at Open Door Mission?
Is the applicant currently incarcerated?
No
Yes
Does the applicant have any active court cases?
No
Yes
If yes, what is the date of the applicants next court case?
-
Month
-
Day
Year
Date
Please describe the offenses and/or charges for any pending cases or offenses currently incarcerated for.
1. What is your drug of choice? (select all that apply)
Alcohol
Cocaine
Crack Cocaine
Ecstasy
Fentanyl
Hallucinogens (LSD, Acid, etc.)
Heroin
Inhalants
Marijuana
Methamphetamine
Other Pills (stimulants)
Other Pills (sedatives)
Other Pills (opiates)
PCP
Other
2. The applicant is aware this is a 4-5 month program and is committed to staying at this center until graduation from program?
Yes
No
3. During the probationary period (minimum of 30 days), the applicant accepts that during this time,he will not leave the campus for any reason other than medical, court, and/or probation/parole appointments.
Yes
No
4. Has the applicant been in a controlled environment at a hospital (psychiatric or medical) or treatment facility for the last 30 days?
Yes
No
5. Has applicant been in a controlled environment because of jail or incarceration in prison?
Yes
No
6. Has the applicant been diagnosed with any medical issues, chronic or otherwise, that will interfere with your ability to complete the program?
Yes
No
If the applicant answered "yes" to question #6, what is your diagnosis?
7. Has the applicant ever been diagnosed or treated for any mental or emotional issues?
Yes
No
If the applicant answered "yes" to question #7, what is your diagnosis?
8. Only approved prescribed medications are allowed (see prohibited medication list). Does the applicant have a 30-day supply of these medications?
Yes
No
9. Is the applicant currently on probation and/or parole?
Yes
No
Both
If the applicant answered “yes” to question #9, please provide the contact information for you probation/parole officer
10. Open Door Mission is a non-smoking campus. Is the applicant willing to participate in a smoking cessation program?
Yes
No
11. An intake assessment will not ensure admittance into the program. Does the applicant have an alternative plan?
Yes
No
If the applicant answered “yes” to question #11, what is the plan?
Submit
Should be Empty: