Carolyn’s Place Pre-Screening Application

For additional information please contact Susie Foreman, Operations Manager, at (707) 373-2020

Carolyn's Place

(Office at the end of the driveway) • 1822 Sutter St. Vallejo, CA 94590 (707) 644-2577 • No Recovery Program or Services Provided by Management

Date

Name

First Last

Date of Birth

Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Social Security Number:

Ethnicity:

Intake Date:

Referral Source

Marital Status:

Children:

How Many Girls

How Many Boys

Is Child Protective Services (CPS) involved in their care?

If you have adult children, are they supportive in your recovery?

Any pending charges?

Ever been convicted of a Crime?

If so, what charges?

Have you ever lived in clean & sober housing?

If so where:

Have you ever been accused or convicted of arson?

Are you on parole or probation?

Any upcoming court dates? If so when:

Name of Probation/Parole Officer

Phone Number

Highest grade completed:

Are you employed:

If so where:

Monthly income:

Age at first use:

What is your drug of choice:

Do you smoke:

Do you take medications?

What Medications:

Do you have physical, mental, or emotional disabilities to prevent you from participating in our program?

If so what are they:

History of Trauma:

Mental Illness Diagnosis:

If so, what have you been diagnosed with?

Are you able to complete routine household chores?

Do you need help with reading and writing:

Emergency Contact:

Relationship:

Phone Number:

Have you been exposed to scabies, ringworm, lice, or similar conditions within the past 60 days? If yes, please describe the treatment you received.

Do you have any known allergies to food, chemicals, medications, or other allergies we should be aware of?

Do you have prob lems getting along with others?

Please explain any history of conflicts or violent behavior..

Resident Print Name

Signature

Operations Manager:

House Manager:

Date

Notes