Screening and Initial Interview Form

 

General

Tell us about yourself
What is your first name?
Client first name
What is your middle name? No middle name? Move on to the next question.
Client middle name
What is your last name?
Client last name
When is your birthdate?
Client birthdate
What is your race/ethnicity?
Client race
What is your marital status?
Client marital status
Are you a veteran?
Client veteran status

Dependent Information 

Family Members

Are you pregnant? 

Dropdown

 If so, how many weeks? 

Text field

 Have you received prenatal care? 

Dropdown

 Who is your medical provider? 

Text field

 Do you have any cases involving children and youth?

 Dropdown

If so, please describe details and give case worker contact info.

 Paragraph

Contact Information

How can we reach you?
What is your email address?
Client email
At what phone number can we best reach you at?
Client phone
Street Address:
Client Address
City:
Client City
State:
Client State
Zipcode:
Client Zip

Contacts

Give us a few people that we can reach out to in case of an emergency.
Contact

Insurance

Enter your insurance provider(s).
Insurance

Medical History

Tell us about your medical history.
When did you last use?
Recovery history 1 relapse date
What is your substance(s) of choice? Add multiple by clicking in the box and selecting different options
Client substances of choice
If you do not have a drug use history, why do you want to come in?
Text field
Have you been clinically diagnosed with anything? Add multiple by clicking in the box and selecting different options
Client diagnosis
Do you have any health problems? Add multiple by clicking in the box and selecting different options
Client health problems
What allergies do you have? No allergies? Move on to the next question.
Client allergies

Have you had any of the following tests?

Medical Tests

Medications

List the medications you are currently prescribed.
Medication

Criminal History

Probation

Do you have any pending criminal charges? Dropdown

Do you have any upcoming court cases? Criminal and/or civil. Dropdown

Do you have any outstanding warrants? Dropdown

Treatment Centers

Tell us about any treatment centers you've previously been admitted into.
TreatmentCenterHistory

Client Referral Source

Who referred you to us?
Client Referred By
 

Employment

Tell us about your employment status.
If you're currently unemployed select "unemployed" under "type"
EmploymentHistory

Living Arrangement

Tell us about your living arrangement prior to moving into this facility
LivingArrangementHistory
 
I understand that by signing below I am expressing interest in entering New Life Center for Mothers and Children. In order to proceed with the interview process I must have a telephone interview by the NLFMC staff. Please provide best phone number to reach you Text field and the best time for the staff to make contact with me Text field. I further understand that an application does not guarantee a bed and it is my responsibility to follow up with NLFMC within a timely manner. Initials Text field
 
Signature:
Signature