Initial Screening

Name *

Preferred Name:

DOB *

Phone number

Does this number receive texts? *

Yes

No

Last Use Date? What Substance? *

Are you currently experiencing withdrawal symptoms? *

Yes

No

If Yes, what substance(s)?

Have you ever been to treatment before? If yes, where and how recently? *

Have you ever been given a behavioral health diagnosis? If so, do you know what diagnosis (e.g., depression, anxiety)? *

What symptoms do you experience? *

What medications are you currently prescribed?

Are you currently working a recovery program (e.g., AA, NA, Celebrate Recovery)? *

Do you have a sponsor? *

What are you hoping to get out of this program? *

Are you currently on Probation? Parole? Drug Court? If so, please provide details. *

Personal Information