PRE-ADMISSION SCREENING FORM

28-Day Faith-based 12-Step Residential Program

SECTION 1: About Client

Resident Full Name: Client first nameClient middle nameClient last name
Age:Text field
Phone Number:Client phone
Current Location (City/State): Client CityClient State

Name of Detox/Behavorial Health Reffered by: 

Text field

SECTION 2: IMMEDIATE ELIGIBILITY SCREEN

Is the individual male and 18 years or older?
Checkboxes

Is he currently under the influence at this time?
Checkboxes

Does he require medical detox?
(Shakes, seizures, hallucinations, history of severe withdrawals?)
Checkboxes

Is he currently prescribed MAT (Suboxone, Methadone, etc.)? 

 Checkboxes

**Please Know if Selecting Yes on MAT a requirement of 30-Day Prescription is a must to be admitted into the program**

 

Any history of violence or aggressive behavior?

Checkboxes
(Explain): Text field

Any active psychosis or untreated severe mental illness?
Checkboxes

SECTION 3: SUBSTANCE USE HISTORY
Primary substance of choice: Text field
How long using? Text field
Last use date: Text field
Average daily use: Text field

History of overdose?
Checkboxes

Previous treatment attempts?

Checkboxes

Number of prior treatments: Text field

SECTION 4: LEGAL STATUS
Is he currently on:
Checkboxes

Is treatment court-ordered?
Checkboxes

Any violent felony history or sex offender registry?
Checkboxes

SECTION 5: MENTAL HEALTH SCREEN
History of diagnosed mental illness?

Client diagnosis

History of suicide attempts?
Checkboxes

Any current suicidal thoughts?
Checkboxes

SECTION 6: PROGRAM UNDERSTANDING
Resurrected Recovery is:
28-day residential
Faith-based
12-Step focused
Structured schedule
Mandatory class attendance
Nightly outside AA meetings

MAT accepted / with prescription
Private pay only / No insurance needed
No refunds

Are you willing to participate in a Faith-based program?
Checkboxes

Are you willing to attend nightly AA meetings?
Checkboxes

Are you willing to follow house rules strictly?
Checkboxes

Are you willing to remain abstinent and submit to drug testing?
Checkboxes

SECTION 7: MOTIVATION & READINESS

Why are you seeking treatment right now?

Paragraph
On a scale of 1-10, how committed are you to change?
Text field

What happens if you don't enter treatment?

Paragraph

SECTION 8: Medical STABILITY

Any current medical conditions requiring monitoring?
Checkboxes

 

Any recent hospitalizations?
Checkboxes

Currently detoxed and medically stable?
Checkboxes

 

Please list any medications the resident is currently taking along with proper dosing, down below.

 Medication