Screening Application Update

SCREENING APPLICATION:

General

First Name: Client first name 

Middle Name: Client middle name 

Last Name: Client last name

Address: Client Address

City: Client City State: Client State Zip: Client Zip

Email: Client email Phone Number: Client phone

Gender: Client gender Birthdate: Client birthdate

School: Client school

Marital status: Client marital status

Race: Client race

Veteran: Client veteran status

Emergency Contact: Contact 1 name   Emergency Contact Phone: Contact 1 phone

Emergency Contact Relationship: Contact 1 type

Attorney Name: Contact 2 name   Attorney Phone:  Contact 2 phone

Attorney Email: Contact 2 email

Judge: Contact 3 name

Probation / Parole / Community Corrects Officer / DHR Worker: 

Name: Contact 4 name  Phone: Contact 4 phone

Name: Contact 5 name  Phone: Contact 5 phone

 

Any pending charges:

Radio buttons 

 

Upcoming Court Dates:

Paragraph

 

Desired Move-in Date: Date

 

Medical History

Diagnosis: Client diagnosis Health problems: Client health problems

Substance of Choice: Client substances of choice

Kinds of meetings attended: Client kinds of meetings attended

Allergies: Client allergies Relapse Date: Client relapse date

Referred by: Client Referred By

License number Text field SS#Text field

Food Stamp Number: Text field Pin #Text field

Are you on any medications? Please list:

Medications

 

Insurance Information:

Health Insurance: 

Checkboxes

Health Insurance Policy

Provider: Client insurance provider Insurance Plan: Client insurance plan

Group ID: Client insurance group ID Policy#: Client insurance policy #

Address:(Street) (City) (State) (Zip) Text field

 

Are you receiving welfare, unemployment compensation, disability payments, workman’s comp, alimony, VA benefits, or other income?

Checkboxes

Explain: Paragraph

 

How would you rate your personal health?

Checkboxes

 

HAVE YOU EXPERIENCED OR DO YOU PRESENTLY HAVE A PHYSICAL AILMENT, INJURY, HANDICAP OR MEDICAL PROBLEM THAT WOULD PREVENT YOU FROM PERFORMING MANUAL LABOR WHILE ENROLLED AT 7 SPRINGS MINISTRIES?

Checkboxes

IF YES, PLEASE EXPLAIN:

Paragraph