Admissions BASIC INFORMATIONName(Required) First Last Date of Birth(Required) MM slash DD slash YYYY This field is hidden when viewing the formAgeAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code PhoneEmail Have you ever been incarcerated?(Required) Yes No List the dates, locations, and length of incarcerations(Required)Are you currently incarcerated?(Required) Yes No Release Date(Required) MM slash DD slash YYYY Arkansas Department of Corrections Number423 Date (if applicable) MM slash DD slash YYYY TE Date (if applicable) MM slash DD slash YYYY CHILDRENDo you have children?(Required) Yes No How old are each of your children?(Required)Who has primary custody of your children?(Required)SUBSTANCE 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)MENTAL & 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 Please list your medications(Required)Have you ever received a mental health evaluation?(Required) Yes No What were you told regarding your mental health evaluation?(Required)Have you received either of the following? (Check any that apply)(Required) Inpatient or residential drug treatment Inpatient psychiatric hospitalization None Date(s) & Location(s) of inpatient or residential drug treatment(Required)Date(s) & Location(s) of inpatient psychiatric hospitalization(Required)EDUCATION & EMPLOYMENT HISTORYPlease tell us about your employment history(Required)CRIMINAL HISTORYHave 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)Are you currently on parole?(Required) Yes No Are you currently on probation?(Required) Yes No County in which you are on probation/parole(Required)What 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
