Name

Email Address

SS #

Date of Birth

Gender Gender MALE FEMALE OTHER

Race

Height

Weight

ARE YOU AN ALCOHOLIC AND/OR A DRUG ADDICT? ARE YOU AN ALCOHOLIC AND/OR A DRUG ADDICT? YES NO

PLEASE CHECK ALL OF THE FOLLOWING FORMS OF ID WHICH YOU HAVE IN YOUR POSSESSION: PLEASE CHECK ALL OF THE FOLLOWING FORMS OF ID WHICH YOU HAVE IN YOUR POSSESSION: BIRTH CERTIFICATE DRIVERS LICENSE SS CARD STATE PICTURE ID

ARE YOU CURRENTLY IN TREATMENT? ARE YOU CURRENTLY IN TREATMENT? YES NO

If Yes, Where and Counselor's Name?

What Type of Treatment? What Type of Treatment? INPATIENT OUTPATIENT INTENSIVE OUTPATIENT

Admission Date

Discharge Date

IF YOU ARE NOT IN TREATMENT, WHERE ARE YOU STAYING NOW?

PHONE NUMBER OF CURRENT LOCATION

PERSON TO ASK FOR IF YOU ARE NOT AVAILABLE

IF INCARCERATED, WHAT IS YOUR EARLIEST PROJECTED RELEASE DATE?

WHEN WAS YOUR LAST DRINK AND/OR DRUG?

WHAT IS YOUR DRUG OF CHOICE?

ARE BOTH YOUR PARENTS LIVING? ARE BOTH YOUR PARENTS LIVING? YES NO

ARE THEY STILL MARRIED? ARE THEY STILL MARRIED? YES NO

WHAT ARE THEIR OCCUPATIONS?

HAVE YOU BEEN DIAGNOSED WITH ANY PSYCHOLOGICAL DISORDERS OTHER THAN ALCOHOL AND DRUG DEPENDENCY INCLUDING MAJOR DEPRESSION, BI POLAR, SCHIZOPHRENIA, PARANOIA, BORDER LINE PERSONALITY, ETC.? HAVE YOU BEEN DIAGNOSED WITH ANY PSYCHOLOGICAL DISORDERS OTHER THAN ALCOHOL AND DRUG DEPENDENCY INCLUDING MAJOR DEPRESSION, BI POLAR, SCHIZOPHRENIA, PARANOIA, BORDER LINE PERSONALITY, ETC.? YES NO

IF YES, LIST EACH ONE

DO YOU HAVE ANY PHYSICAL HEALTH PROBLEMS INCLUDING HERNIA, HEPATITIS B, HEPATITIS C, HIV VIRUS, BACK PROBLEMS, OR OTHER LIMITATIONS? DO YOU HAVE ANY PHYSICAL HEALTH PROBLEMS INCLUDING HERNIA, HEPATITIS B, HEPATITIS C, HIV VIRUS, BACK PROBLEMS, OR OTHER LIMITATIONS? YES NO

IF YES, LIST EACH ONE

ARE YOU CURRENTLY ON ANY MEDICATION? ARE YOU CURRENTLY ON ANY MEDICATION? YES NO

IF YES, LIST EACH MEDICATION

ARE YOU CURRENTLY RECEIVING SSI OR DISABILITY INCOME? ARE YOU CURRENTLY RECEIVING SSI OR DISABILITY INCOME? YES NO

IF YES, WHY ARE YOU RECEIVING IT?

WHAT IS THE MONTHLY AMOUNT?

LIST EVERYTHING THAT YOU HAVE EVER BEEN ARRESTED FOR. EXAMPLE: DUI X 3, ETC.

DO YOU HAVE ANY LEGAL CHARGES PENDING NOW? DO YOU HAVE ANY LEGAL CHARGES PENDING NOW? YES NO

IF YES, LIST COURT DATE(S)

LIST CHARGE(S)

ARE YOU CURRENTLY ON PROBATION? ARE YOU CURRENTLY ON PROBATION? YES NO

IF YES, NAME OF P.O.

P.O. PHONE #

ARE YOU COURT ORDERED TO LIVE IN A HALF WAY HOUSE? ARE YOU COURT ORDERED TO LIVE IN A HALF WAY HOUSE? YES NO

DO YOU HAVE $350 ADMISSION FEE(150 1ST WEEK,150 REFUNDABLE DEP.+ 20 MISC. DEP DO YOU HAVE $350 ADMISSION FEE(150 1ST WEEK,150 REFUNDABLE DEP.+ 20 MISC. DEP YES NO

DO YOU UNDERSTAND THAT THERE ARE NO REFUNDS IF YOU ARE NONCOMPLIANT? DO YOU UNDERSTAND THAT THERE ARE NO REFUNDS IF YOU ARE NONCOMPLIANT? YES NO

DO YOU HAVE VERIFIABLE EMPLOYMENT? DO YOU HAVE VERIFIABLE EMPLOYMENT? YES NO

IF NOT EMPLOYED OR IF YOU BECOME UNEMPLOYED ARE YOU WILLING TO TAKE A JOB WASHING DISHES? IF NOT EMPLOYED OR IF YOU BECOME UNEMPLOYED ARE YOU WILLING TO TAKE A JOB WASHING DISHES? YES NO

ARE YOU IN A RELATIONSHIP? ARE YOU IN A RELATIONSHIP? YES NO

IF YES, HOW LONG?

PERSONS NAME

IS IT YOUR SPOUSE? IS IT YOUR SPOUSE? YES NO

ARE YOU WILLING TO GO A MINIMUM OF 30 DAYS WITHOUT TALKING TO THIS PERSON? ARE YOU WILLING TO GO A MINIMUM OF 30 DAYS WITHOUT TALKING TO THIS PERSON? YES NO

IF NOT IN A RELATIONSHIP ARE YOU WILLING TO STAY OUT OF A RELATIONSHIP FOR ONE YEAR? IF NOT IN A RELATIONSHIP ARE YOU WILLING TO STAY OUT OF A RELATIONSHIP FOR ONE YEAR? YES NO

ARE YOU WILLING TO WORK ALL TWELVE STEPS BEFORE LEAVING TURNING POINT ? ARE YOU WILLING TO WORK ALL TWELVE STEPS BEFORE LEAVING TURNING POINT ? YES NO

ARE YOU WILLING TO FOLLOW ALL OF THE SUGGESTIONS AT TURNING POINT? ARE YOU WILLING TO FOLLOW ALL OF THE SUGGESTIONS AT TURNING POINT? YES NO