Date

Name Age

  1. How many times have you been in Jail?

  2. Are you married? Yes No

  3. Have you ever been suicidal? Yes No

  4. What is your purpose in life? (you may write as much as 250 words)
     

  5. Do you have any children? Yes No
      If yes, how many?

  6. Were your parents married when you were born? Yes No

  7. Did your parents get a divorce? Yes No

  8. Are both of your parents alive? Yes No
      If no, which parent has died? Mother Father Both

  9. Were either of your parents addicted to drugs? Yes No
      If yes, which parent? Mother Father Both

10. What drug did your parent(s) use?

11. Did your parents drink alcohol? Yes No
      If yes, which one? Mother Father Both

12. Are (or were) your parents alcoholics? Yes No
      Mother Father Both

13. Have you ever committed adultery on your mate? Yes No

14. How many times have you been married?

15. Estimate how many people you have had intimacy with in your life.

16. Do you have children out of wedlock? Yes No
      How many?

17. Are you in trouble with the law? Yes No
      What are your charges?
     

18. Have you lost all your money? Yes No

19. Have you lost your driver's license? Yes No
      Your Car? Yes No

20. Did your mate leave you? Yes No

21. Are you employed? Yes No
      What is it?

22. Have you lost your home? Yes No

23. Have you been abused? Mentally Physically Sexually Verbally

24. Have you been diagnosed with anything? Yes No
      Describe what?
     

25. Do you drink? Yes No Smoke tobacco? Yes No

26. What age did you first use drugs/alcohol?

27. Do you want to stop using? Yes No

28. Does your mate? Yes No

29. What is your drug of choice?

Click here To Print This Form, after you have filled it out please fax it along with your completed
application to Good Samaritan Rehabilitation at 208-667-4078