* 1. What is your full name?

* 2. What is your primary phone number?

* 3. Are you 18 years of age or older?

* 4. Have you been released from a facility within the last 60 days?

* 5. What is your marital status?

* 6. Are you on the sex offender registry?

* 7. At what age was your first arrest or charge?

* 8. Under the age of 18, were you ever detained for a criminal offense? 

* 9. Under the age of 18, what was your most serious offense?

* 10. Were you ever suspended or expelled from school?

* 11. Was your most recent offense drug-related?

* 12. What is your total number of adult felony convictions?

* 13. While incarcerated, have you ever received infractions for violent behavior?

* 14. Do you have previous parole violations for missed appointments with a parole officer?

* 15. Were you employed at the time of your latest arrest?

* 16. Have you ever quit a job prior to finding another place to work?

* 17. Have you ever felt a sense of pride in a past criminal offense?

* 18. Do you believe that it is possible to move beyond a history of criminal offenses?

* 19. Have you ever used anger to intimidate someone else?

* 20. Do you walk away from confrontation?

* 21. How would you rate your ability to solve problems?

* 22. How concerned are you for others' well-being?

* 23. In what ways will participating in the Get Help App Phone Program improve your life?

* 24. Do you have any additional comments you would like to add?

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