Intake form

Thank you for considering The WellHouse as your place of faith-based restoration and healing.

Below is an intake form to provide The WellHouse with some basic information. Please complete the entire form and include a phone number or email that can be reached after 5 PM (CST). Feel free to ask any questions you may have during your intake call.
Once submitted, please allow 24 hours for contact to be made in order to complete the verbal portion.
If Saturday or Sunday (any time) is better for you, please specify. This call typically takes 15-30 minutes.

Name

First Name

Last Name

Association with Survivor

Phone

(###)

###

####

Rescue Status

Survivor is currently safe.

Survivor is in need of immediate rescue.

Survivor Information

Survivor's Name (If Different Than Above)

First Name

Last Name

Phone (If Different Than Above)

(###)

###

####

Date of Birth

YYYY

Current Location (City & State)

Are you currently in a program?

Program Name

Case Manager / Advocate's Name and Contact Information:

If not in a program, please provide the best contact information for yourself:

Are you currently struggling with Substance Abuse?

If yes, please include the following information. Drug of choice, any additional substances used, how long have you used, and the last time you used:

Have you ever been to a Substance Abuse Program?

If yes, please answer the following: How long were you there? Did you graduate? Your reason for leaving?

Have you been diagnosed with any mental illnesses?

If yes, please list each diagnosis and what age you were approximately diagnosed:

Are you pregnant?

What date and time works best for you to complete the verbal portion of the Intake process?