Barbara’s Place Pre-Screening

Please note: If you meet the criteria of our prescreening test the full application will be able to be downloaded  (you will need to print out the application at the end of the screening).

If you are not able to meet the pre-screening criteria at this time, and you get a “FAIL” message. Please call (848) 227-4591 x 1046 for further questioning.

 

I am filling this out for:(Required)
Name(Required)
Address(Required)
Please enter a number greater than or equal to 18.
Do you smoke or use other tobacco products?(Required)
Do you take any psychotropic medication? (Any mood/mind-altering substance or prescribed narcotic)
Any outstanding legal issues?(Required)
Pending jail time?(Required)
Court dates?(Required)
Is this program being court mandated? *If yes, this will disqualify you(Required)
Are you physically able to climb stairs on a regular basis? *If no, this will disqualify you(Required)
Do you have any issues with food?(Required)
Are you a part of any self-destructive behavior? (such as cutting, burning, etc.)(Required)
Can you physically handle light work therapy? *If no, this will disqualify you(Required)

Have Questions?