Abbe's Sanctuary for Women

Fill out the questionaraire below. Print out form and fax to 602-633-2557. 

Name:                                                         

 Date:

 Phone:

                    How did you here about us/or who referred you to us?

 1.     Tell me about your current situation?

 2.     Where are you staying at now?

 3.     When was the last time you drank/used?

 4.     What was the longest clean time you’ve ever had?

 5.     What was your drug of choice?

 6.     Are you on meds? Y or NO.

 7.     If yes on meds, are any of them Benzo’s, Opiates, or Narcotics?

 8.     Do you have a medical diagnosis?

 9.    Have you ever lived in a halfway house before? Y OR N

 10.  If yes where, how long ago, and what happened?

 11.   Are you employed or on disability?

                    12. If no on job, what type of work did you do before?

 13.   Are you willing to follow rules? 

 14. Are you willing to follow a 12 step program?

 15. How well do you get along with other women?

 16. How are you with someone telling you what to do?

 17. Tell me why you think you need to come here?

 18. Are you on probation? Y or N. If yes, who is your probation officer?

 19. Do you have an open CPS case? Y or N. If yes, what is your case workers name and phone number?

 20. Are you a sex offender? Y or N.

 21. Are you willing to go to any lengths to stay sober? Y or N.

 22. Do you have any questions?

If you are in prison please answer the following:

1. What is your DOC number?

2. What is your release date?

3. Are you case managed by Magellan?

4. Do you have the entrance fee? 

                     The move in cost is $285.00. That covers your 1^st week,  your food for the month, and a $50.00 entrance fee.