Intake Questionnaire | Fresh Start

Your Name *

First

Last

Email Address

Please enter your email, so we can follow up with you.

Phone Number

Who are you filling this out for? *

How did you hear about the FSNB Program?

Date of Birth *

ADC#

Date of Release

Drug(s) of choice

How have drugs or criminal activity affected your life?

Are you willing to commit to 90 days in the program? *

Are you a registered sex offender? *

How are you with someone telling you what to do? *

Why do you need to come here? *

List some of your job skills *

What is your medical history? *

Do you have HIV? *

Hep A, B or C? *

Are you SMI? *

Taking Medication? *

Do you have seizures? *

Are you Diabetic? *

Have you had a stroke? *

Have you had a heart attack? *

Have you ever been in a halfway house before? If Yes, where and how long ago? Describe your experience. *

In as much detail as possible, outline your disciplinary record. *

Describe your feelings and why you are ready to take ownership of your recovery and why help will enable change. *

I have completed this form with complete honesty and to the best of my knowledge and ability. *

Name