Pre-Screening Form Name(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Social Security Number Phone(Required)Email(Required) Do you have insurance?(Required) Yes No What insurance do you have?(Required) Medicaid Commercial Insurance Insurance Number (11 digits)(Required) Name of Insurance Company(Required) Group Number(Required) Member ID(Required) Do you have a substance use disorder?(Required) Yes No Drug(s) of choice? Last Day of use? MM slash DD slash YYYY Are you experiencing withdrawal?(Required) Yes No Do you need detoxification?(Required) Yes No Are you enrolled in MAT?(Required) Yes No Are you in good standing?(Required) Yes No Provider/Clinic Name/Medication Dose: Date of last dose taken? MM slash DD slash YYYY Have you been tested for covid-19?(Required) Yes No When/result? Paperwork ResultsMax. file size: 64 MB.Do you have any medical complications that prevent you from using stairs? Example: walker, cane, etc(Required) Yes No If yes, list:(Required) Are you diagnosed with a mental health disorder?(Required) Yes No What is your diagnosis?(Required) Are you prescribed medication?(Required) Yes No What medications:(Required) Are you homicidal or suicidal?(Required) Yes No Do you have a 30-day supply of your medication?(Required) Yes No If no, how much do you have?(Required) Do you have any upcoming appointments within the next thirty (30) days?(Required) Yes No Do you have any abscesses or open wounds?(Required) Yes No Any legal involvement?(Required) Yes No If yes, describe?(Required) Are you willing to engage in behavioral health treatment as recommended by Clinician?(Required) Yes No Is there a discharge summary and/or referral form/admission information?(Required) Yes No Please Attach(Required)Max. file size: 64 MB.Completed by: (Signature)(Required)Date(Required) MM slash DD slash YYYY
