Pre-Qualifying Form Orientation Packet Name * First Name Last Name Email * Age * Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Are you currently taking medications? * Yes No 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. All romantic involvement will be looked at on individual basis. If it is deemed an unhealthy relationship for the client all involvement will be asked to cease. Is this something you are willing to do? * Yes No Are you a registered sex offender? * Yes No Please check any and all that apply below. I am on parole I am on probation I am incarcerated I 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? Yes No 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? * Yes No Please indicate who referred you to CareCenter Ministries. By checking this box you agree that all information you have entered is true. * I Agree Thank you!