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
