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Personal Intake Informatiion

Sending Authority; Are currently under the supervision of any of the following?

State or Federal Probation Offficer

Community Sentencing

DA Supervision

Judge Authority

Drug Court

Other

Marital Status

Military History

Work History

Job History

Drivers Licence

Physical and Mental Health

Do you now or have you ever had any of the following: Please select all that apply

High Blooid Pressure

Arthritis

Heart

Back problems

Neck problems

Problems with legs

Problems with feet

Migraines

Broken bones

Liver problems/ Hepatitis

Metal in bones/ surgical implants

Glasses

Seizures

Diabetes

Carpal Tunnel Syn.

Thyroid issues

Hand issues

Any other medical issues please add here

List all current and previous medications and why prescribed

Have you ever been diagnosed with a mental illness?

If yes, list conditions, any treatment programs and medicine prescribed for mental illness

Abuse History

Age of first alcohol and drug use?

Last date alcohol or drugs used

Age when use begun problems in your life?

Please list alcohol and drugs of choice.

Have received any previous treatment for substance abuse?

If yes, please list programs and dates; as well if you completed or not.

Please list Family history of substance abuse. Include all know relatives

Have you attended AA or NA meetings?

Do you consider yourself to have a alcohol or drug problem?

If yes, please explain what your willing to do about it.

Legal History

Please list previous convictions- include 1. charge 2. date of offense 3. location 4. dates of incarceration [also include current names of Attorneys, Probation officers, and Judges assoiciated with cases.]

Do you have any current charges pending in Municipal, State or Federal courts?

Thanks for submitting!

D.A.R.P FOUNDATION

Contact Us
Men's Facility
Phone 918-770-3647
Fax 479-752-3411

Women's Facility
Phone 9184539919
Fax 9184581065

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