Name
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First Name
Last Name
DOB
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Height and Weight
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Marital Status
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Email
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Phone
(###)
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1. How did you hear about the Caldwell House?
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2. Have you successfully completed 14 or more days in a 12-Step inpatient treatment program?
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Where and When (If no, put N/A)
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3. Have you ever lived in a sober living house before?
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Where and When (If no, put N/A)
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If currently in treatment, list the name of the facility and when you'll be discharged.
4. Are you a Veteran of the Armed Forces?
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5. PRIMARY substance(s) abused?
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Date(s) of last use?
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6. Have you had any 12-step experience in the past?
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When? How long?
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7. Current doctor’s name and phone number? (If none, put N/A)
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Date of last exam?
MM
DD
YYYY
8. List any psychiatric or medical diagnosis(es). (If none, put N/A)
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9. List any communicable diseases (TB, HIV, Hepatitis A B C). (If none, put N/A)
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10. List any allergies. (If none, put N/A)
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List any dietary restrictions. (If none, put N/A)
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12. Do you have a history of seizures?
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13. List all medications and dosages you are currently taking. (If none, put N/A)
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14. Have you recently stopped taking medications without your doctor’s permission?
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15. Have you ever been convicted of assault, arson, or of an offense involving a child, juvenile, minor, or senior-aged person?
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List: (If none, put N/A)
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16. Do you have any pending legal issues, court dates, or charges?
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Where and when? (If none, put N/A)
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17. Are you on probation or parole?
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What for and where? (If no, put N/A)
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Probation/Parole officer name and phone number. (If none, put N/A)
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18. What do you do for work?
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Are you currently working now? Where?
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19. Do you have a drivers License?
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Do you have a car insured in North Carolina?
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Do you have a social security card?
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20. Are you on disability or receiving benefits?
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21. Do you have any disabilities that would prevent you from working a full-time, first-shift job?
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22. Why do you want to come to the Caldwell House?
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23. What is the most important thing in your life right now?
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24. Are you open to getting a 12-Step sponsor?
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25. Other than drinking/using, what is one thing you would like to change about yourself?
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26. If admitted, are you willing to stay a minimum of 4 months?
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27. Do you have the $600 initial service fee to come to the Caldwell House?
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If no, what can you pay?
*
28. Is there anything else you think we should know prior to you becoming a resident at the Caldwell House?
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I understand that the Caldwell House will be conducting a background check and will be verifying the statements and representations on this form. I swear, under penalty of disqualification of residency at the Caldwell House, that the above is true and correct. I authorize the Caldwell House, its agents and assigns, to conduct background checks and verify any statement that I make. I further agree to hold harmless and free from any liability the Caldwell House and its agents and assigns, and any person or organization providing information, for any action that may occur as a result of this information. This release shall continue in effect for (2) two years from the date signed/initialed below.
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Initial
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Date
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MM
DD
YYYY
