Questionnaire

    General Information

    Marital Status

    Do you have any children?

    Do you have a driver's license or other form of identification?

    Do you own or have the use of a vehicle?

    Emergency Contact

    Employment

    Are you currently employed here?

    Sober History

    Special Situations (Community Control, House Arrest, Probation)

    Aftercare Facility

    Medications

    Medicine
    Dosage
    Physician

    Comments