Eval Questionaire Apply online below or print a PDF application Eval Questionaire - Short Personal Information Name DOB MM slash DD slash YYYY Address City State Zip PhoneEmail Social Security # Highest Level of School completed:ElementaryHign SchoolSome CollegeAssociates DegreeBacholars DegreeTechnical School Substance Abuse History 1st Drug of Choice: First Usage (what age): Last Usage (date): 2nd Drug of Choice: First Usage (what age): Last Usage (date): 3rd Drug of Choice: First Usage (what age): Last Usage (date): Are you Currently using: Yes No If yes, what substance or substances:Allergies: Yes No If yes, to what:Current Medications:Mental Health Diagnosis or Concerns:Physical Health Diagnosis or Concerns: Criminal History Are you currently on Parole or Probation? Yes No If yes, who is your probation officer?Do you have pending Legal issues requiring treatment? Yes No If yes, what legal issues? Family Do you have any children? Yes No If yes, how many and who do your children live with??Do you have a family or friend support system (non-using family and friends)? Goals, Strengths, & Weaknesses What are yourshort-term goals?What are your long-term goals?What are your strengths?What are your weaknesses? Health Care Coverage Do you have health care coverage? Yes No Unsure If yes, what insurance or Insurances?1st Policy name:2nd Policy name:1st Policy number:2nd Policy number:Signature Donate PHONE: 701-751-0318TEXT LINE: 701-660-0767FAX: 701-751-2354 *protected email* Location: OFFICE: 701-751-0318 FAX: 701-751-2354 MON-THURS 10am - 5:30pm 2700 State St. Ste F-6 Bismarck ND 58503 (Gateway Mall)
