PRE-SCREENING QUESTIONAIRE Providing false information on this assessment may result in your application being denied and your eligibility for admission to our program may be revoked.Full Legal Name(Required)DOB(Required) MM slash DD slash YYYY Phone or number to leave a message(Required)Do you currently have a substance use disorder?(Required) Yes No Do you have any limitations that may affect your ability to obtain or maintain full time employment?(Required) Yes No Please explain(Required)Are you able to independently manage activities of daily living (ADL), such as feeding yourself, dressing yourself and bathing yourself?(Required) Yes No Do you have a criminal history or any violent convictions?(Required) Yes No Please explain(Required)Are you currently listed on a sex offender registry?(Required) Yes No Do you have charges in any other state?(Required) Yes No If yes, please specify the state(s(Required)Have you been diagnosed with any mental health conditions?(Required) Yes No If yes, explain diagnosis and what medications you are taking(Required)Once you have submitted this screening, please allow up to 24 hours for a case manager to get back to you. If you do not have a contact number, please feel free to contact us after the 24 hours. Submitting false information on this assessment could lead to the denial of your application and disqualification from consideration for admission to our program. Is there anything you would like to change. pre-screeningquestionaire08.18.25FINAL
