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BASIC INFORMATION

First Name *

Last Name *

Date of Birth *

Age *

Phone

Have you ever been incarcerated? *

List the dates, locations, and length of incarcerations *

Are you currently incarcerated? *

Release Date *

ADC Number *

423 Date (if applicable)

TE Date (if applicable)

COVID-19 POLICY

MSH residents and staff are required to have the COVID-19 vaccine.

Do you have the COVID-19 vaccine? *

Are you willing to get the vaccine?

CHILDREN

Do you have children? *

How old are each of your children? *

Who has primary custody of your children? *

SUBSTANCE ABUSE HISTORY

What are your drug and alcohol preferences? (Check all that apply)

Alcohol
Marijuana
Crack/Cocaine
Benzodiazepines
Prescription Drugs
Opiates
Barbituates
Hallucinogens
Heroin
Meth
Other
None

What 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 HEALTH

Do you have any physical disabilities or limitations? *

Please describe your physical disability and/or limitation(s) *

Are you currently on any medications? *

Please list your medications *

Have you ever received a mental health evaluation? *

What were you told? *

Have you received either of the following? (Check any that apply) *

Inpatient or residential drug treatment
Inpatient psychiatric hospitalization
None

Date(s) & Location(s) of inpatient or residential drug treatment *

Date(s) & Location(s) of inpatient psychiatric hospitalization *

EDUCATION & EMPLOYMENT HISTORY

Please tell us about your employment history *

CRIMINAL HISTORY

Have you been charged with any violent or sexual crimes? *

Check all charges you have had: *

Assault
Battery
Sexual offenses
Weapons charges
Other violent charges

What other violent charges have you had? *

Do you have any felonies? *

Type of felony *

Do you have any pending cases? *

Are you currently on parole? *

Are you currently on probation? *

County in which you are on probation/parole *

ADDITIONAL QUESTIONS

What 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: *