WNCC Prescreen and
New Resident Form
Prescreen and New Resident Form
Please note that all fields followed by an asterisk must be filled in.
Social Security Number*
Social Security Number*
First Name*
First Name*
Last Name*
Last Name*
E-mail Address
Date of Birth (mm/dd/yyyy)*
Date of Birth (mm/dd/yyyy)*
Gender*
Gender*
Male
Female
Ethinicity*
Ethinicity*
---Select---
\n
Caucasian
African American
Hispanic
Asian
Native America Indian
Other
Prescreen Date (mm/dd/yyyy*
Prescreen Date (mm/dd/yyyy*
Prescreen Outcome*
Prescreen Outcome*
Accept
Reject
Reason for Rejection
---Select---
\n
No Income/Funding
Criminal Background
Actively Using
No Vacancy
Mental Health Instability
Medically Unstable
Other
Mental Health Status*
Mental Health Status*
Drug of Choice*
Drug of Choice*
Alcohol
Cocaine/Crack
Heroin
THC
Prescription Drugs
Meth
Other
Date of Last use (mm/yyyy)*
Date of Last use (mm/yyyy)*
Income Source*
Income Source*
Treatment Status
---Select---
\n
Day treatment
Outpatient treatment
Aftercare
None
Education Level
---Select---
\n
H.S. Diploma
GED
HSED
Assoicates Degree
College/College Degree
Vocational/Occupational Trainig
Legal Status
---Select---
\n
Probation
Parole
Justice 2000
None
Marital Status
---Select---
\n
Single
Married
Divorced
Separated
Military Status
---Select---
\n
Veteran
Service Non-Connection
Army
Navy
Air Force
National Guard
Reserves
Currently Homeless (Y/N)*
Currently Homeless (Y/N)*
Yes
No
Referral *
Referral *
---Select---
\n
WIser Choice
Treatment Center
Probation/Parole
Drug Court
Self
Bureau CW
Other
Move in date (mm/dd/yyyy)
Resident Maintenence and Discharge Form
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