Step #1 Screening and Initial Interview Form

Screening and Initial Interview Form


Date of Online Submission: Date  Form Completed by: Text field

Name: Client first name Client middle nameClient last name  Date of Birth:  Client birthdate

Where are you calling from? Text field  

Counselor Name: Therapist/Clinician Counselor Phone Number:  Text field

How did you hear about Char Hope? Paragraph

Most recent home address: Client Address Client City Client State Client Zip

 Do you have housing?  Text field How long without it? Text field  

Who in your family is supportive of you coming to Char Hope? Family Members


Emergency Contact: (Please provide emergency contact phone number) Contact

Is there someone or an organization/institution that can help you with your intake fee or rent at Char Hope, if needed? Paragraph


What are your drugs of choice? Client substances of choice  What was your method of use? (Inhale, IV, smoke, oral): Text field

How long have these drugs been problematic? Text field  Are there any other drugs that you have used regularly? Client medical notes

When was your last use of any mood altering substances?  Date  



What treatment centers have you been to in the past: TreatmentCenterHistory What recovery homes have you attened? SoberLivingHistory

Have you ever been discharged from a treatment program for non-compliance? Paragraph

Have you achieved any clean and sober time? Text field RecoveryHistory

Have you ever participated in a therapy group? Paragraph


Do you have any significant medical or health problems that would be difficult for you to manage if accepted into Char Hope? Client health problems

Have you been diagnosed with any mental health problems or disorders?  Client diagnosis

Do you have a history of self-harm or eating disorders? Client health problems

What medications are you currently taking, Dosage, and for what purpose? Medication

Name of physician and phone # that monitors your medications: Paragraph

Do you have medical insurance? Text field

If so what types: Insurances  



Are you currently married or in a committed relationship? Client marital status 

If married, how does your spouse feel about your coming to Char Hope? Paragraph

Do you have children? (If yes, what are the ages and childcare arrangements?) Child Welfare History

Do you think you would have difficulty locating a job soon after arriving at Char Hope? Paragraph

Do you have any legal issues? (probation, court dates, open warrants) Criminal History

Do you have the necessary documents for obtaining employment? (Social security card, photo ID) Paragraph

What are your most marketable job skills? Paragraph

Are you familiar with 12-Step programs? Paragraph

Char Hope requires 12-step meeting attendance, obtaining a sponsor and home group, and working steps.  Do you have a problem with this expectation? Paragraph

Why have you decided to go to a half-way house? Paragraph

What do you hope to achieve while a resident at Char Hope? Paragraph

What are three of your strengths or assets? Paragraph

By continuing, you agree that your electronic signature is the legally binding equivalent to your handwritten signature. Whenever you execute an electronic signature, it has the same validity and meaning as your handwritten signature. You will not, at any time in the future, repudiate the meaning of your electronic signature or claim that your electronic signature is not legally binding.