Admissions The following screening questionaire is to provide essential information that is neccessary to determine who is an appropriate candidate for the Flint Odyssey House Program. It is imperiative that the following questions are answered thoruoughly and honestly. You must answer and give a full description of your individual history. If the information obtained leaves any doubt concerning acceptability, contact us and call the Admissions Administrator at (810) 238-5888 * Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 12345678910111213141516171819202122232425262728293031 Name and Street Address * City * State * Zipcode * E-Mail address Phone Date of Birth * Race Religion Emergency Contact/ Relationship * Name * Address * Phone Please list number of children that will be entering the facility with you. Please give their names and ages separated by numbers, 1-6 etc. * Have you ever been incarcerated? If so please list all charges and time served, below. Have you ever been involved in any violent crime? (i.e. murder, assault with a deadly weapon, criminal sexual assault, etc.) * Yes No If yes, please explain, with dates and time served. * Have you ever attempted arson? * Yes No Are you currently on probation or parole, or under charges or supervision of CPS? * Yes No Please type your full name at the end of this questionaire. By typing your name you certify that all the information given is true to the best of your knowledge and ability. * |Welcome| |Our Mission| |Our Services| |The TC| |For Women| |Children Services| |Exec. Director| |Health Center| |Job Training| |Outpatients| |FAQ| |Admissions| |Adm. Personal History| |Adm/Med/history| |Adm./Psycho/History| |Directions| |Odyssey Links| |Contact Us| |About| This website is sponsored by a grant from the Robert Wood Johnson Foundation