Page 1Page 2Page 3Page 4BASIC INFORMATIONFirst Name *Last Name *Date of Birth *0102030405060708091011120102030405060708091011121314151617181920212223242526272829303132212321222121212021192118211721162115211421132112211121102109210821072106210521042103210221012100209920982097209620952094209320922091209020892088208720862085208420832082208120802079207820772076207520742073207220712070206920682067206620652064206320622061206020592058205720562055205420532052205120502049204820472046204520442043204220412040203920382037203620352034203320322031203020292028202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923Age *Phone Have you ever been incarcerated? *YesNoList the dates, locations, and length of incarcerations * Are you currently incarcerated? *YesNoRelease Date *ADC Number *423 Date (if applicable) TE Date (if applicable) COVID-19 POLICYMSH residents and staff are required to have the COVID-19 vaccine.Do you have the COVID-19 vaccine? *YesNoAre you willing to get the vaccine? YesNoCHILDRENDo you have children? *YesNoHow old are each of your children? *Who has primary custody of your children? *SUBSTANCE ABUSE HISTORYWhat are your drug and alcohol preferences? (Check all that apply) AlcoholMarijuanaCrack/CocaineBenzodiazepinesPrescription DrugsOpiatesBarbituatesHallucinogensHeroinMethOtherNoneWhat other types of drug/alcohol do you prefer? *Age you began using drugs/alcohol *When was the last time you used drugs/alcohol? *What is the longest period of abstinence you have had? *MENTAL & PHYSICAL HEALTHDo you have any physical disabilities or limitations? *YesNoPlease describe your physical disability and/or limitation(s) *Are you currently on any medications? *YesNoPlease list your medications *Have you ever received a mental health evaluation? *YesNoWhat were you told? *Have you received either of the following? (Check any that apply) *Inpatient or residential drug treatmentInpatient psychiatric hospitalizationNoneDate(s) & Location(s) of inpatient or residential drug treatment *Date(s) & Location(s) of inpatient psychiatric hospitalization *EDUCATION & EMPLOYMENT HISTORYPlease tell us about your employment history * CRIMINAL HISTORYHave you been charged with any violent or sexual crimes? *YesNoCheck all charges you have had: *AssaultBatterySexual offensesWeapons chargesOther violent chargesWhat other violent charges have you had? *Do you have any felonies? *YesNoType of felony *Do you have any pending cases? *YesNoAre you currently on parole? *YesNoAre you currently on probation? *YesNoCounty in which you are on probation/parole *ADDITIONAL QUESTIONSWhat goals do you want to achieve during your residency in this program? * What other program options have you explored or completed? * Can you tell us what worked well for you in those programs? * What was not helpful to you in the other programs? * What has caused you to relapse or reoffend? * What do good boundaries look like for you? * MSH is a community. What do you think are some benefits of living in a community? * How do you handle a conflict or problem with another person? Include an example. * What questions do you have about our program? For security purposes, please enter an answer to the following problem: * = MessageBackNext PageSubmit Join Our Newsletter Subscribe to our newsletter for monthly updates Success! Email Subscribe