Screening Form

Screening Form

Please fill out this form to the best of your ability. Please be truthful this form does not automatically make you eligible or ineligible for the program. This form is for screening purposes only to determine if you are eligible to enter the program. All information recorded below is confidential information and will not be shared with any other entity. The program does not discriminate based on age, race, sex, or political association.
Name*

First NameLast Name
Social Security Number (warrant checks only)
Date of Birth*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
Please answer the following questions:
Do you have a substance abuse problem?*

YesNo
If yes, when was the last time you had a drink/drug?
Are you currently under the influence of a substance?*

YesNo
Do you have a problem with being in a Christian program?*

YesNo
What is your religious belief? Explain…..*
Have you ever been or are you currently involved in a gang?*

YesNo
If yes, give some details:
What felonies or convictions are on your record?*
Are you a U.S. Citizen?*

YesNo
If not, do you have a green card?

YesNo
Are you able to pay a $750 monthly rent fee?

YesNo
Family Questions
Are you currently married?*

YesNo
Are you currently living with your spouse?*

YesNo
Will this person be contacting you while you are in the program?

YesNo
Does this person have a drug/alcohol issue?

YesNo
Do you have any children?*

YesNo
If yes, how many? What are their ages?
If yes, have arrangements been made for childcare?

YesNo
Do you currently have children in the CYFD system?

YesNo
If yes, how many? Are they long-term or short-term?
Were you referred by CYFD?

YesNo
Medical
Do you have high blood pressure?*

YesNo
Do you suffer from epileptic seizures?*

YesNo
Are you currently taking medication?*

YesNo
If yes, please state which medications:
Do you have any communicable disease?*

YesNo
Do you have a history of violence?*

YesNo
Have you ever been treated for mental illness?*

YesNo
Have you ever attempted suicide?*

YesNo
Have you ever thought about committing suicide?*

YesNo
Do you have a current Driver’s License or ID?*

YesNo
Do you have medical insurance?*

YesNo
Do you have any physical disabilities?*

YesNo
If so, what are they:*
History of illness or accidents:*
Are you currently under a doctor’s care?*

YesNo
If so, what is/are the reason(s)?
List all medications you are currently taking, the dosage, the reason you are taking them, and the prescribing doctor(s):*
Are you able to physically handle the requirements for this program?*

YesNo
Additional comments regarding your health:
Employment / Legal
Are you currently working?*

YesNo
What is your source of income?*
Are you willing to commit to 1 year in this program?*

YesNo
Are you currently on probation or parole?*

YesNo
Are you court ordered/mandated?*

YesNo
For how long?
Probation Officer
Judge
Court
Do you have any immediate court dates?*

YesNo
Are you volunteering to come into this program?*

YesNo
Do you have to register as a sex-offender?*

YesNo
Do you have any outstanding warrants?*

YesNo
Do you have to find a program due to any violation?*

YesNo
How would you describe your current circumstances/situation?*
Why do you believe Under His Construction will help you?*
Do you have any other comments you would like to make? If so, please do so below:
Agreements
I have read and understand the House Rules and will make every attempt to be compliant. I understand what the consequences are if I do not follow these rules and am subject to dismissal at any time for not complying with these rules.*

YesNo
I have read and understand the Program Schedule and will make every attempt to complete all scheduled programming. Prior approval is required for absence or leaving early.*

YesNo
I have read and understand the Smoking Waiver and agree to quit smoking.*

YesNo
I agree that all the information provided by me has been answered truthfully and to the best of my ability. I understand that the information provided is for the sole purpose to determine my eligibility and to best help the Recovery Program determine the type of services I will need. Please use your mouse or finger to sign below.
Signature
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Screening Form

Please answer the following questions:

Family Questions

Medical

Employment / Legal

Agreements