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Reentry Halfway House Client Application
Calling All Men to the Development Of Character (CAMDOC)
1300 NE 8th Street, OKC, OK 73117
admin@camdoc.org 
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Thank you for your interest in Calling All Men to the Development Of Character (CAMDOC) Halfway House Program. This application has been developed to assist individuals in making decisions regarding their long-term recovery goals. For an individual to be considered for the Halfway House Program, please follow the steps outlined below:

It is encouraged that you read ALL information that is provided within this application and complete all questions fully. The link provided below should be read prior to completion of the application and contains important information about the Halfway House you may want to retain. It is encouraged that you print this out for our own records.

Also, please provide a valid email address for your referral source so they may complete the referral portion of your application.

Once the Halfway House receives the required application forms back, a determination will be made for eligibility to our program. We will then contact you to discuss eligibility and to review next steps.

There may be a waiting list. It is your responsibility to follow up weekly to check the status of the waiting list. Do not assume that you have been approved unless directly informed by us.

Please direct all questions you may have to the Halfway House Staff at the address and email listed above.


CAMDOC Reentry Halfway House Info 
Prescreening Application
Full Name (First and Last) *
Date of Birth *
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Age *
Gender *
Current Address: *
City *
State *
Zip code: *
Emergency Contact Name *
Relationship: *
Emergency Contact Phone Number: *
Primary Care Physician: *
Physician Location/Address: *
Psychiatrist (if applicable):
Current Medications (both prescribed and over-the-counter): *
Last TB Test Date:  *
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Location/Physician: *
Special Needs/Accommodations:
Any medical conditions/allergies/chronic pain:
Source of Income: *
Required
If yes, how much do you receive or earn per month?
If no, who provides your financial support?
Do you have insurance and/or Medicare/Medicaid? *
Do you have a registered/insured vehicle you intend to bring? *
Do you have a valid driver’s license? *
Referral Source: *
Referral Source Email: *
Referral Source Phone Number: *
Are you currently in Substance Abuse Treatment? *
If yes, location:
If yes, what type:
Clear selection
If yes, admission date to current treatment:
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If yes, estimated discharge date:
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If no, when and where did you last receive treatment?
Questionnaire
Instructions: Please answer the following questions to the best of your ability.
PRESENTING PROBLEM:
Why are you inquiring about a Halfway House? *
What do you expect from staying at a Halfway House? *
DRUG USE:
Describe your drug use history. Include the drugs you used, the amount, and the duration of use. Have you ever overdosed? *
What was your last date of use? *
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SUPPORT SYSTEM:
Who is supportive of your recovery? Describe them. *
Is there anyone who negatively impacts our recovery? Describe them. *
Please list the names of any children, their current and expected living arrangements, including custody/visitation schedules. *
VOCATIONAL:
What is your highest level of education completed? *
Please list any certifications you have. *
Do you have any goals or plans for continued education? Describe. *
What work experience have you had? *
Are there any restrictions that will not allow you to work? Explain. *
Do you have any unpaid debts such as past bills, court fines, medical bills, etc.? Describe. *
LEGAL:
Are you currently incarcerated? *
If yes, at what facility?
If yes, what is your estimated release date?
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What is your legal history? Please include the county of arrest, any jail or prison stays, convictions, and current status of parole, probation, probation officer, and upcoming court dates. *
MENTAL HEALTH:
If applicable, please list any mental health diagnoses. *
Do you have any history of psychiatric hospitalizations within the past year? Explain. *
Do you have any history of suicide attempts? If so, when? *
Do you have any history of cross addiction (i.e., eating disorder, self-harm, gambling, love/sex, etc.)? *
RECOVERY EFFORTS AND GOALS:
Have you ever participated in a recovery program? Please explain your experience and any preferences. *
Are you currently sponsored or mentored? *
What sacrifices or changes need to be made for you to remain in recovery? *
What do you want to accomplish while being at the Halfway House? *
How long do you project it will take for you to meet these goals? *
What are your plans after you leave the Halfway House? *
By typing your full name below, you are verifying that you have read the document provided in the link above and have completed this application to the best of your ability. *
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