Healing Point Eligibility Screening Application

Healing Point House

Initial Eligibility Assessment Application
Today's Date: *

Month Day Year
Applicant name: *

First Name Last Name
Are you currently 18 years or older? *

Yes No
Have you ever resided in Ozaukee County? *

Yes No
Please indicate the year of your most recent Ozaukee County residency: *
In which Wisconsin County do you currently reside? *
Phone number: *
Please enter a valid phone number.
Email:
example@example.com
Marital Status *

Single Married Divorced Widowed
How were you referred to Healing Point House? *
Substance Use
What is the date of your most recent use of alcohol or other substances? *

Month Day Year
Date
12-Step/SMART Recovery
I have participated in a 12-Step program: *

Yes No
I currently have a sponsor: *

Yes No
I am willing to find a sponsor: *

Yes No
I am currently working the 12-Steps: *

Yes No
I have worked other programs besides 12-Steps, like SMART Recovery or something else: *

Yes No
Name of program *
Legal
Do you have any convictions for arson, violence, weapons, or sexual based offenses? *

Yes No
Medical
Are you currently prescribed any narcotics such as hydrocodone, oxycodone, or morphine, or are you currently prescribed Suboxone? *

Yes No
If yes, please describe prescriptions: *
Do you require any accommodations for accessibility at Healing Point House? *

Yes No
Please explain required accommodations: *
Employment
Current income range: *

$0 - $10,800 $10,801 - $24,000 $24,001 - $50,000 $50,001+
Are you currently employed? *

Yes No
Do you believe you can find employment within the next month? *

Yes No
Do you have financial commitments that may cause you difficulties in paying the program fee? (Program fee is $125/week) *

Yes No
Please explain: *
Please list all your sources of income: *

Healing Point House

Substance Use

12-Step/SMART Recovery

Legal

Medical

Employment