Prescreening Questionnaire

Complete the Questionnaire

This form can be filled out by individual or family member,

This information will be sent to outreach staff to be reviewed with director.

If determined eligible, someone will reach out to schedule an intake.

Who referred you/them, how did you hear about our program?

What is your/their primary diagnosis?

What level of care is being recommended?

Do you have a current history of drug or alcohol abuse?

What was your/their drug of choice?

When was the last time you/they used?

How often/much have you recently used?

What medications are you/they currently on?

Any Injectable Medications? (Yes/No)

Date Last of Injectable Received?

Date of Next injection Due?

What other programs have you/they attended?

Do you/they have a history of suicidal thoughts or attempts?

Do you/they have a history of violence or aggression?

Do you/they report to any outside agencies?

Do you/they have any Legal Involvement?

Do you/they have a job? (or any outside obligations?)

What are those hours?

Are these hours flexible/set?

Will these hours conflict with our hours?

Why are you/they seeking treatment now?

First name

Last name

Address

Phone number

Medicaid Number

Date of visit

You agree to our friendly privacy policy.

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