Project Hope Florida Form

Project Hope Interview Questionnaire - Ft Walton Beach Florida
Person Filling Out This App (Your Name)
Personal Information:
Full Name

First Name Middle Name Last Name
Date of Birth
ex; 01/13/2018
Do you have Identification (DL ID SS Card Birth Cert)

Yes No (IF No Student cannot be accepted)
Social Security Number
Have You Ever Been to Or Completed a Program Before?

Yes No
If Yes Where Was The Program.
What center are you interested in?
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Phone Number

Area Code Phone Number
Highest Level of Education Completed
Are you able to read/write ?
Sexual Orientation

Straight Gay Bisexual
Are you..

Single Married (Legally) Divorced
How many children do you have
Legal Questions

Court Probation etc
Are you on probation or parole?
If Yes Please explain.
Officer Name:
Officer Phone Number:
Officer Fax:
Officer Email:
City/State:
Have you ever been convicted of sex crime?
Do you have any court dates or pending charges?
If yes please explain?
Drug / Alcohol History
What was your Drug(s) of Choice?
When is the last time you used and what?
How many Days/Weeks/Months have you been consecutively using?
Are you in need of a detox?
Do you currently use any tobacco products?
Personal and Medical History
Do you have medical insurance?
If yes what
Do you or have you had any of these conditions?

Hepatitis HIV / AIDS STD's TB Asthma High Blood Pressure Diabetes Epilipsy
If yes please explain:
Any medical conditions that would hinder you from working?
Known Allergies
Food Allergies?
If so what?
Any other medical conditions that we need to be aware of?
Please list any medications you are currently taking. YOU MUST ANSWER THIS
IF none Please write NONE
Mental Health
Have you ever been diagnosed with any mental health conditions past or present ?
If so then what are they
Have you ever been suicidal?
If yes then please explain the circumstances
We do ask for a $1000 non refundable induction fee. Are you able to pay this full amount or to make payments?

Yes Full $1000 Yes 2 x $500 Yes 3 x $333 No i cant afford
Disclosure

We are NOT a Medical Facility If you are due for a doctors checkup or are in need of dental work, we strongly advise that you take care of that before you entering our program. YOU WILL NOT see a doctor for at least 90 days unless it is an emergency.

The only meds that you are allowed to bring are the meds we have talked about in this interview. If you claim to need a medication that you did not mention in your interview you will not be allowed to get that medication.

Expect Discomfort once your body is clean and sober you will feel pain that your DOC was numbing.

After going over this interview are there any further questions that you have for me at this time?
The interview is now completed If you are interested in coming to our program i will need you to Read the Rules of the Program and sign them before arriving. Please Provide a Email address Where they can be sent to you.
Personal Notes
Should be Empty:

Project Hope Interview Questionnaire - Ft Walton Beach Florida

Legal Questions

Drug / Alcohol History

Personal and Medical History

Mental Health