Mission Statement
Admission
Residential
Services
Contact Us
On-Line Screening
TurnAround and the Judicial System
On-Line Screening
In this section, if you do not have a home address, list your next of kin, your relationship to that person and their address (you must list family and phone numbers so we may contact them)
Full Name 
E-Mail 
Facility 
Referred By 
SSN 
DOB 
Home Phone 
AGE 
Other Phone 
Address 
City 
State 
Current Relationship 
Name of Partner 

If you have a prearranged employment, list your employer’s name, address, and phone number. If you do not have a job lined up, list all your work skills and some previous employers. We will not contact any previous employers, we only want to have an idea of your work skills so that we may help you find employment upon release.
Employer 
If unemployed, list your work skills

List any previous treatment for mental health or substance abuse. If you are unsure about any if the information, try to be as accurately as possible, but indicate that the information is a guess. If there are more than three, write the other(s) on a sheet of paper and attach.
Treatment Center 
Phone 
Counselor 
Doctor 
Admission Date 
Discharge Date 
Patient Number 
Aftercare 

Treatment Center 
Phone 
Counselor 
Doctor 
Admission Date 
Discharge Date 
Patient Number 
Aftercare 

Treatment Center 
Phone 
Counselor 
Doctor 
Admission Date 
Discharge Date 
Patient Number 
Aftercare 

In this section, list any secondary diagnoses you may have, physical or mental. When listing medications, list name, amount taken, dosage schedule, and doctors name.
Disorders other than addiction 
Current medications used 
Have you ever attempted suicide 
 Yes No
If yes when and how ?

Date of last drug use 
Drug of Choice 
Drugs Used 
R
  Recent: Regular use of this drug with the past year.
 
P
  Past Only: Regular use but not used in at least a year.
 
E
  Experimental Only: Only tried 1 to 3 times in my life.
 
N
  Never: Never used this drug.
 
M
  Medical: A legal prescription, taken as prescribed.

Pick P R E N or M for each of the drugs below
Past       Recent       Experimental       Never       Medical
 DEPRESSANTS  CANNABIS  STIMULANTS
 Alcohol  Marijuana  Cocaine
 Benzodiazopine  Hash  Amphetamine
 Barbituates      Inhalants
         Ice
 NARCOTICS  HALLUCINOGENS  OTHER
 Opiates  LSD
 Morphine  Psilocybin 
 Codeine  Mescaline    
 Methadone  XTC MDA    
           

 Comments about your drug use.

In this section, list all criminal issues, with dates, jurisdiction, and disposition. Also indicate whether or not the case is closed or current (active).
Active or
Non-active 		Date Place of Jurisdiction List the Charges Disposition

If you plan to bring a vehicle to Turn Around, complete the following information. You must have a valid license and current insurance to bring your vehicle. List license number and state of issuance in this section.
Vehicle Type
Year
Make
Model
D/L # & State

 How do you plan to pay your admission fees to Turn Around?
 How do you plan to maintain your financial obligation to Turn Around?
 How long will you commit to staying at Turn Around?
 Why do you want to come to Turn Around?

By initialing this form, I affirm the information is true and correct, to the best of my knowledge. I authorize Turn Around to contact any other agency to arrange for my placement into the Turn Around Program. I further authorize Turn Around to investigate my involvement or participation with any of the persons or with any of the agencies listed. I further authorized the release of any information to Turn Around from any of the persons or agencies, for the purpose of determining my eligibility to enter the Turn Around Program. I further authorize Turn Around to investigate my past criminal history, medical history, or mental health/substance abuse history, and for Turn Around to request documentation from any agency that could provide this information. I agree to hold harmless, any agency which is contacted by Turn Around, for the release of any information requested to determine my acceptance to the Turn Around Program.
Applicant's intitials 
Todays Date