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Intake Questionnaire
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Home
Leon’s Story
Our Program
Important Files
Intake Questionnaire
Donate
Intake Questionnaire
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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?
*
Yourself
Someone Else
What is your relationship to the other person?
*
Name of Person for Intake
*
First
Last
How did you hear about the FSNB Program?
If filling this out for someone else, answer from their point of view
Date of Birth
*
ADC#
Date of Release
Drug(s) of choice
Last used?
How have drugs or criminal activity affected your life?
Are you willing to commit to 90 days in the program?
*
Please choose
Yes
No
Are you a registered sex offender?
*
Please choose
Yes
No
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?
*
-
Yes
No
Hep A, B or C?
*
-
Yes
No
Are you SMI?
*
-
Yes
No
Taking Medication?
*
-
Yes
No
List your medications
*
Do you have seizures?
*
-
Yes
No
Are you Diabetic?
*
-
Yes, Type 1
Yes, Type 2
No
Have you had a stroke?
*
-
Yes
No
Have you had a heart attack?
*
-
Yes
No
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.
*
-
Yes - I understand that any misrepresentation on my intake form will result in immediate expulsion from the program
Email
Submit