Screening and Initial Interview Form
IDENTIFYING INFORMATION
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
SUBSTANCE ABUSE HISTORY
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
PRIOR TREATMENT & ABSTINENCE:
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
PHYSICAL HEALTH:
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
OTHER PERTINENT INFORMATION:
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.