Age: Birth Date: Social Security Number: Drivers license or id #: Make and model of vehicle? Vehicle Tag #: Vehicle Color: Person to contact in emergancy? Phone Number: Contact address: Contact relation: Second contact name? Second contact phone number? Second contact address? Second contact relation? Are you a member of any Church or Christian organization? WHO REFERRED YOU TO THIS PROGRAM? Layout Do you have a valid license to drive? Yes No ALCOHOLIC? YES NO Do you have an automobile? Yes No OTHER DRUGS? Yes No Have you been through a rehabilitation facility or a Florida Recovery home before? Yes No DATE OF LAST DRINK? LAST DRUG & DATE? Reason for leaving: Relapse Disruptive behavior Voluntary Other Prior living situation: Streets Jail/prison Friends/relatives Transitional housing Marital status: Single Married Divorced Separated How long? Name of spouse: Spouse address: Are you involved in an intimate relationship with someone? Yes No How long? Name: Address: NUMBER OF CHILDREN: Ages of children? Where do your children live? Do you have to pay child support? Yes No Payment amount? When? Are you behind in paying? Yes No How much? When was the last time you saw your children? Address: Age Job: Status: Living Deceased Religion: Address: Age: Job: Status: Living Deceased Religion: Address: Age: Job: Status: Living Deceased Religion: Address: Age: Job: Religion: Status: Living Deceased Address: Age: Job: Religion: Status: Living Deceased Address: Age: Religion: Status: Living Deceased Address: Age: Religion: Status: Living Deceased Address: Age: Religion: Status: Living Deceased ARE YOU PRESENTLY EMPLOYED? No Yes – Part Time Yes – Full Time Employed by? How long? Address: Phone number: Owner or immediate supervisor: Phone number: Position: Responsibilities: What type of job skills do you have? What other type of skills do you have? 1) PREVIOUS EMPLOYER: Position: Start & end dates: Reason for leaving: Attitude towards job: 2) PREVIOUS EMPLOYER: Position: Start & end dates: Reason for leaving: Attitude toward job: 3) PREVIOUS EMPLOYER: Position: Start & end date: Reason for leaving: Attitude towards job: EDUCATION: How far did you get in school (grade)? School: Address: Did you graduate? Future education goals? Ever attend a vocational or technical school? Have you ever felt the call of God in Your Life? Yes No Explain: CRIMINAL HISTORY: Do you have any charges pending? Yes No Court date: Judge: Hearing date: Attorney name: Attorney address: Terms of probation: PRIOR CRIMINAL HISTORY #1) Include Date / City / State / Charge / Disposition PRIOR CRIMINAL HISTORY #2) Include Date / City / State / Charge / Disposition PRIOR CRIMINAL HISTORY #3) Include Date / City / State / Charge / Disposition PRIOR CRIMINAL HISTORY #4) Include Date / City / State / Charge / Disposition PRIOR CRIMINAL HISTORY #5) Include Date / City / State / Charge / Disposition PRIOR CRIMINAL HISTORY #6) Include Date / City / State / Charge / Disposition RESIDENCY OR EMPLOYMENT INQUIRY RELEASE
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MEDICAL HISTORY: Doctors name: Doctors address: Phone number: When did you last see a doctor? For what? Have you been taking any Doctor prescribed medication in the last year? Yes No What are you taking? Present physical complaints or problems? Have you ever had problems with (check all that apply) If yes to any of the above, explain: Have you ever gone to counseling before? yes no For what problem? Are you currently receiving help from anyone else? yes no Where? Have you ever attempted suicide? yes no Explain: DO YOU CURRENTLY HAVE A DRUG OR ALCOHOL PROBLEM? yes no Have you used any drug or alcohol in the past 3 days? yes no What? Have you ever been in treatment before? yes no Where? Do you like getting high? yes no Do you feel this is a problem for you or your family? yes no Have you ever felt guilty or shame about your addiction? yes no Do you want help? yes no Your addiction is either a bad habit, a wounded soul, which is a reaction to some tragedy in your life or demonic activity. Of the three reasons above, which one is it for you? Explain.