Screen Reader Mode Icon Check SCREEN READER MODE to make this survey compatible with screen readers. Start the Refuge Prescreen Assessment Next Question Title * 1. Contact Information Full Name City State -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming Phone Number Next Question Title * 2. What is your date of birth? Date / Time Date Next Question Title * 3. What is the last 4 digits of your social security number? Next Question Title * 4. Which ministry are you applying for? Men's Women's Next Question Title * 5. How did you hear about us? Word of mouth Referral from another treatment facility Religious organization Other Next Question Title * 6. Are you currently on any medications? If so, please list. Next Question Title * 7. Do you have a mental health diagnoses? Yes No Next Question Title * 8. Do you have any injuries or ongoing physical conditions? Yes No Next Question Title * 9. What drug(s) have you recently taken? Alcohol Cocaine Heroin Meth Pills THC/ Marijauna Methadone Suboxone Benzodiazepines (Ativan, Valium, Xanax) Other Next Question Title * 10. How often do you use? Every day A few times a week About once a week A few times a month Once a month Less than once a month Next NEXT
