Start the Refuge Prescreen Assessment

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* 1. Contact Information

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* 2. What is your date of birth?

Date

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* 3. What is the last 4 digits of your social security number?

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* 4. Which ministry are you applying for?

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* 5. How did you hear about us?

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* 6. Are you currently on any medications? If so, please list.

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* 7. Do you have a mental health diagnoses?

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* 8. Do you have any injuries or ongoing physical conditions?

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* 9. What drug(s) have you recently taken?

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* 10. How often do you use?

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