Screening form

iF you would like to be considered for finding the family, please complete the form below. Our team will review your application and get in touch with you shortly. 

We appreciate your willingness to share your story with us and we look forward to connecting with you.


Name *
Name
Date of Birth
Date of Birth
Address
Address
Home Phone
Home Phone
Cell Phone
Cell Phone
Marital Status
FAMILY DYNAMICS
Name of Spouse
Name of Spouse
Are you currently living on your own or with someone?
MEDICAL HISTORY
Please include STDs, as applicable.
Substance Abuse Problems
Have you ever attempted suicide?
Please list program name, date, and reason for treatment.
Please check all areas below that you are currently concerned about:
Are you currently involved with the Criminal Justice System?
Do you have a history of violence?
Do you have a history as a sex offender?
Please list three (3) references, their phone numbers and how long you've known them.
How did you become aware of Finding the Family?
By submitting this form, I understand:
•  this program is a mentoring/training program and that the staff at finding the family are not counselors. A licensed professional counselor will be available if needed or deemed necessary by staff at finding the family. • I understand that completing this form does not solidify admittance to finding the family. I understand that this is a screening form to determine eligibility. • I understand that finding the family requires a health screening at the Health Department upon admittance into the program.