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

Date: ________     

 

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

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) and Charges___________________________________________

Prison (Facility) and Charges _________________________________________ 

If in jail/prison provide name and number to contact______________________________________________

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

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

Officer Name_________________________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   ___________________________________________________________________

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_______________________________________________________________

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 state beds available that do not cost anything. These state beds 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. 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) 

Are you able to work 40 hours a week      Yes   or    No           

When would you like to come into the facility _________________________________________________

Do you have 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 __________________________________________________________________

 

___________________________________________

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 also provides three meals a days plus resident can have snacks or sodas brought to them. 

WOMEN’S CLOTHING LIST                    MENS CLOTHING LIST                  

7  Pairs of Shoes                                                                        5 Pairs of Shoes

7 Pairs of Pants                                                                          7 Pairs of Pants

3  Hoodies/Sweatshirts                                                           3 Hoodies/Sweatshirts

4 Sweaters                                                                                  2 Sweaters

15 Other Shirts                                                                          12 Other Shirts

3 Dresspants/Slacks/3 Dresses or Skirts                             3 Dresspants/Slacks/3 Suits

7 Undershirts                                                                             5 Undershirts

10 Underwear/10 Socks/5 Bras                                             10 Underwear/10 Socks

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

2 Jackets (Lightweight or Zip-up Sweaters)/2 Coats             2 Jackets/2 Coats