Online Assessment for Treatment

 Please fill out the assessment form below to the best of your knowlege. All information must be completed before you will be assessed for the program. PNS Staff will contact you once they have reviewed your information. You can email, mail or fax this form to us. Our information is listed below.

ASSESSMENT FORM

      

 

This one page assessment will determine which home you qualify for.

Date: ______________

First Name ____________________________         M.I. _________          

Last Name _________________________________ 

Date of Birth _______________      Phone: _______________________   

What town, county, and state are you from: _____________________________________________________   

Female    Male     Race_____    Age  ___         Height  ___        Weight  ___               

Do You Have Active Driver’s License _____________________________

Where would you be coming from?         Home         Hospital____________________  

 Jail (Facility Name) __________________________________________

(If coming from jail once you have been released you must come straight here.) 

Have you been to prison?  Yes  or   No    If so how many times ___________      

ADC/DCC #______________

Are you a convicted felon?   Yes     or     No

Please state all previous convictions  ________________________________________________________________

Have you ever been charged or convicted of a sexual offense?  Yes  or  No 

If yes what charge? ______________________________________                                                                            

A Violent Crime?  Yes or   No      If yes then what charge:  _________________________

Are you on probation or  parole? (Circle One) Felony-Misdemeanor-Juvenile 

Officer _______________ Phone #________________ County _______________

Any upcoming court dates  ___________   When is court date  ___________________                                           

Is court date   District   or   Circuit ?  What county? _________________________________

What are your charges?  ____________________________________________________________________

Do you have a lawyer, if yes please state name and phone number ____________________________________________________________________

If you have a lawyer is it court appointed     Yes                         No 

 Do you know anyone or have a relative in our program  _________________________________________________                  

Have you ever been in our program before  ______________     If yes when _____________                    

Why do you want to enter into program?      Drugs        Alcohol          Depression           Homeless     

If drugs; what type?_____________________________

What is your sexual orientation?  Straight              Gay              Lesbian                   Bisexual

Do you have any medical problems? _________

If yes list them ____________________________________________   

Are you pregnant? Yes or No    If yes how many weeks_____________________

Ever been diagnosed with a mental illness?____________________________

Are you taking any medications? _____ List them_______________________________

If yes, do you have your medication? _______(You must bring your medications in with you.)

Do you have insurance for your medical needs? YES or NO

Medication that can be abused, is narcotic, a sedative, or can get you high will not be allowed. Are you willing to voluntarily cease taking any medication that fall in the previously mentioned categories? ______________

*There is a 1 Month blackout. No mail, visits, or phone calls during that time. You may only receive  any mail during this time. Are you okay with this?___________________________

We have two options available for housing. Project New Start asks for $500 non-refundable donation to enter our recovery program. Please circle  Yes    or     No      if you have donation. If you are not able to pay the $500.00 donation, there are homelss beds available that do not cost anything. These are based on availability. If yes then the donation must be cash or cashier’s check. You must have money present when you enter the program or you will not be admitted.

PNS is a 1 year tobacco free faith based spiritual boot camp program that can be completed in 6 months with good behavior. You will not get a certificate of completion until after you have been in the program for at least 6 months and you have successfully completed the program. Do you agree to this?  __________

Are you collecting a check of any type        Yes   or   No     If yes what type  ____________

Why are you collecting a check?  _________________________

How much  _________ (45% of that will be donated towards PNS each month is this OK? It will not exceed $400.00 a month.) YES or NO

Are you physically and mentally able to do chores and 40 hour a week volunteer work for PNS?   YES  or  NO           

# of Kids  _______     Where are your kids  ____________________     

Do you need help with housing for kids while you are here? ___________________

Are your kids in DHS custody  __________.  If yes then provide DHS casework name, county and phone number __________________________________________________________________

When would you like to come to the facility? ________________________

___________________________________________

Your Signature

Your assessment will be reviewed and someone will contact you to advise you if you are accepted.

 Please send your assessment to Project New Start, P.O. Box 885, Newport AR 72112 (Phone: 870-523-8413) or by (Fax:870-217-0912) or Email pnshomes@yahoo.com

PACKING LIST

The clothing list below are the items you may bring to our facility. Since our clothing areas are limited please only bring what is listed as well as the amount listed (all extra clothing will be return with family/friends that brought you). No residents are allowed to have any clothing with secular music on them nor any sayings on bottoms of pants.  PNS has the right to refuse any clothing items that are not deemed appropriate for the facility.  Residents do need to bring towels, bath towels and toiletry items (such as makeup, hair dryers, curling irons,  hairspray, gel etc)when they come in. Please make sure not to bring aerosol cans nor mouthwash with alcohol. They are not allowed cell phones, ipods  ipads, books, CDS, radios etc. All housing has bunk beds with sheets and comforters provided but residents can bring these items too. PNS provides three meals a days and residents will be allowed to keep money on their books so that they may order snacks and other items from commissary.   

WOMEN’S CLOTHING LIST                     MEN’S CLOTHING LIST                  

4  Pairs of Shoes                                                     4 Pairs of Shoes

(Dress Shoes & Work boots)                               (Dress Shoes & Work boots)

7 Pairs of Pants                                                      7 Pairs of Pants

3 Sweaters                                                               3 Sweaters

10 Other Shirts                                                       10 Other Shirts

2 Dress Pants/Dresses/Skirts                              2 Dress Pants/Slacks/Suits

5 Undershirts                                                           5 Undershirts

7 Underwear/7 Socks/5 Bras                                7 Underwear/7 Socks

2 Sets of Pajamas/Thermals                                 2 Sets of Pajamas/Thermals

2 Coats                                                                       2 Coats

2 Towels                                                                     2 Towels

Bible                                                                            Bible

Shampoo, Soap, Razors                                          Shampoo, Soap, Razors

Toothbrush & Toothpaste                                      Toothbrush & Toothpaste

Comb/Brush                                                              Comb/Brush

We provide Bedding                                                 We provide Bedding

NO AEROSOLS                                                         NO AEROSOLS