Pre Qualifying Form – Carecenter

First Name

Last Name

Email Address

Phone

Age

Address

Street Address

City

State/Province

ZIP / Postal Code

Country

Are you currently taking medications?YesNo

If yes, please list all medications and the reason(s) they have been prescribed (including all psychiatric medication). CareCenter Ministries staff will evaluate any and all medications. We will contact you to inform you should any of your medications deem you unacceptable for admittance.

Are you a registered sex offender?YesNo

Please check any and all that apply below.I am on paroleI am on probationI am incarceratedI have outstanding warrants

Please explain the nature of your situation in the box below. Example, term of parole/probation, warrants and fees, etc.

This is a non-smoking facility, are you willing to stop smoking and quit using any form of tobacco products?YesNo

If you discharge from the program you will have 7 days to pick up your clothing from the office in Dallas. If you do not pick up your clothing items after that they will be distributed into the clothing closet. Do you understand and agree to this?YesNo

Please indicate who referred you to CareCenter Ministries.

By checking this box you agree that all information you have entered is true.Yes

CareCenter Ministries

CareCenter Ministries