Admissions BASIC INFORMATIONName(Required) First Last Date of Birth(Required) AgeSubmission DatePhoneEmail Alternate Contact First Last Alternate Contact PhoneAlternate Contact Email Current Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Which forms of ID do you currently have? Check all that apply. State ID Driver's License Social Security Card Birth Certificate Food Stamp Medical Insurance Other If Other, which form of ID?Relationship Status Single Married Separated Divorced Living with Partner If in a relationship, do you still talk to this person? Yes No CHILDRENDo you have children?(Required) Yes No Are you currently pregnant?(Required) Yes No How old are each of your children?(Required)Do you have custody of your children?(Required) Yes No Who has primary custody of your children?(Required)Do you have a good relationship with their guardian?(Required) Yes No EDUCATION & EMPLOYMENT HISTORYHighest Grade Completed?(Required)121110987654321KHigh School Diploma/GED?(Required) Yes No Are you currently working?(Required) Yes No Employment History:EmployerPositionStart DateEnd Date Add RemovePlease tell us about your employment historyMENTAL & PHYSICAL HEALTHDo you have any physical disabilities or limitations?(Required) Yes No Please describe your physical disability and/or limitation(s)(Required)Are you currently on any medications?(Required) Yes No Medication List:(Required)MedicationDosageTreatment For Add RemoveDo you anticipate any upcoming medical procedures?(Required) Yes No Will this procedure limit your ability to begin working?(Required) Yes No Have you ever received a mental health evaluation?(Required) Yes No Mental Health EvaluationsDiagnosisDateProviderMedication Add RemoveHave you received either of the following? (Check any that apply)(Required) Inpatient or residential drug treatment Inpatient psychiatric hospitalization None Inpatient or Residential Drug Treatment(Required)LocationDiagnosisProgram Completed? Add RemoveInpatient Psychiatric Hospitalization(Required)LocationDiagnosisProgram Completed? Add RemovePlease list your medicationsSUBSTANCE ABUSE HISTORYWhat are your drug and alcohol preferences? (Check all that apply) Alcohol Marijuana Crack/Cocaine Benzodiazepines Prescription Drugs Opiates Barbituates Hallucinogens Heroin Meth Other What other types of drug/alcohol do you prefer?(Required)Age you began using drugs/alcohol(Required)Please enter a number from 0 to 130.When was the last time you used drugs/alcohol?(Required)What is the longest period of abstinence you have had?(Required)Have you ever been on Suboxone/Methadone/Subutex?(Required) Yes No If yes, when was the last time?(Required) CRIMINAL HISTORYHave you ever been incarcerated?(Required) Yes No Incarcerations(Required)LocationDate (Month/Year)Length Add RemoveAre you currently incarcerated?(Required) Yes No Release Date(Required) Arkansas Department of Corrections Number423 Date (if applicable) TE Date (if applicable) Have you been charged with any violent or sexual crimes?(Required) Yes No Check all charges you have had:(Required) Assault Battery Sexual offenses Weapons charges Other violent charges What other violent charges have you had?(Required)Do you have any felonies?(Required) Yes No Type of felony(Required)Do you have any pending legal issues?(Required) Yes No What county are these pending charges in?(Required)Do you have any Failure to Appear (FTA) charges pending?(Required) Yes No Are you currently on parole?(Required) Yes No County in which you are on parole(Required)Are you currently on probation?(Required) Yes No County in which you are on probation(Required)List the dates, locations, and length of incarcerationsWhat were you told regarding your mental health evaluation?Date(s) & Location(s) of inpatient or residential drug treatmentDate(s) & Location(s) of inpatient psychiatric hospitalizationADDITIONAL QUESTIONSWhat goals do you want to achieve during your residency in this program?(Required)What other program options have you explored or completed?(Required)Can you tell us what worked well for you in those programs?(Required)What was not helpful to you in the other programs?(Required)What has caused you to relapse or reoffend?(Required)What do good boundaries look like for you?(Required)MSH is a community. What do you think are some benefits of living in a community?(Required)How do you handle a conflict or problem with another person? Include an example.(Required)What questions do you have about our program? Δ
