(701) 751-0318

Eval Questionaire

Apply online below or print a PDF application



Eval Questionaire - Short

Personal Information

MM slash DD slash YYYY

Substance Abuse History

Are you Currently using:

Criminal History

Are you currently on Parole or Probation?
Do you have pending Legal issues requiring treatment?


Do you have any children?

Goals, Strengths, & Weaknesses

Health Care Coverage

Do you have health care coverage?


OFFICE: 701-751-0318
FAX: 701-751-2354

MON-THURS 10am - 5:30pm

2700 State St. Ste F-6
Bismarck ND 58503
(Gateway Mall)