Assessment Form - Harrisburg

Please complete as much information as possible so that we can quickly determine your eligibility for the Why Not Prosper program and get you enrolled. Information with an *asterisk is required.

Assessment Form - Harrisburg

Harrisburg Location

* Indicates required field

Name *

First

Last

Date of Birth *

Age *

Email or Last Known Phone Number *

Referral Source/Prison *

Prison # or Last 4 of Social Security # *

Have you ever been in treatment before? If Yes, add facility name and year of treatment. *

Release Date *

Counselor/Case Manager Name *

First

Last

Counselor/Case Manager Phone Number *

Parole Officer Name *

First

Last

Parole Officer Phone Number *

Work History (Please list your last 3 jobs and years of employment) *

Medical History (For example, diabetes, asthma, high blood pressure, etc.) *

Mental History (For example, depression, anxiety, or bipolar disorder) *

Do You Have a Drug or Alcohol History? *

If Yes, Last Date of Drug/Alcohol Use *

Do you have a Religion? If yes, then pick one from the dropdown menu. *

Number of Children and Age of Each Child *

Level of Education *

Do You Have Any Income? *

Please List Any Current Medications You're Taking *

Type of Arrest *

Current Charges *

Past Charges *

In What Part of the City Did You Used to Hang/Use In? *

Have You Been a Victim of Domestic Violence? *

Yes No

Do You Need to Register with Domestic Relations (For example, child custody, parental rights Issues)? *

Yes No

Submit

Assessment Form - Harrisburg

​Assessment Form - Harrisburg

Assessment Form - Harrisburg