7th Street Admissions Screening Form

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Once added to the wait list, please check in weekly to stay on the wait list.

FULL NAME

What level of care are you seeking? *

Residential

PHP (Day Treatment)

IOP (Intensive Outpatient)

Date of birth *

YYYY

Gender Identification *

Phone Number *

Email Address *

Address where you are currently living (if homeless, type homeless). *

Lawyer or Probation Officer name and phone number (if this does not apply, type "N/A") *

Insurance Name (if no insurance, type "N/A")

Insurance policy/member ID number (if no insurance, type "N/A") *

Inmate Number if applicable

Are you or have you been pregnant in the last 90 days? *

Yes

Do you have any current Gang affiliation? *

Yes

Have you been homeless for 12 months total out of the last 3 years or have you been homeless for 6 months out of the last 12 months? *

Yes

What drugs/alcohol have you been using? *

To ensure we meet state requirements and provide you with the best care possible, please answer the following:

Have you ever received services from a syringe exchange program?

Yes

Other:

Required

Date of last use? *

YYYY

Any history of self harm in the last 90 days? *

Yes

Have you attempted suicide in the last 30 days and/or do you currently have suicidal ideation? *

Yes

Any physical health concerns? *

Do you have physical limitations that limit daily activities like walking up stairs, walking around the block, performing chores, or any other physical activity? If so, what is the limitation(s)? *

Do you have a history of seizures? *

Yes

Any Allergies to food, medication, or environment? *

Any mental health concerns? Have you been diagnosed with a mental health disorder? If so, what are they? *

When sober, do you see or hear things that are not really there? *

Yes

Have you had any legal charges for acts of violence or of a sexual nature? If so, please explain *

What medications are you currently taking? *

Please understand that we request that you bring a minimum of 14 days of your medications and that we cannot guarantee that you will be able to obtain your medications within several days of admission.
*

I understand and will agree to follow 7th Street's medication protocol

I do not agree and understand that I may not be able to participate in treatment

7th Street does not allow for some medications within Subutex, benzodiazepines (Xanax, Valium), Gabapentin, Lyrica, stimulant medications (Adderall), opiates (Lortab, Percocet), etc. You will not be able to take these medications while in treatment. *

I understand and will agree to follow 7th Street's medication protocol

I do not agree and understand that I may not be able to participate in treatment

Have you received services with 7th Street before, if so, what level of care? *

How did you hear about 7th Street? *

Why do you want to come to 7th Street? *

Clients in residential services are only allowed a total of 14 outfits including pajamas. Please bring in, if available, winter clothing including jacket and coat. No tank tops allowed, nothing tight, revealing, gang related, or drug/alcohol related clothing. We often participate in activities that call for gym attire. *

I agree to follow the clothing limitations

I do not agree

Disclaimer: Any false or misleading information provided in this form prior to admission may result in discharge from our services. *

I understand and state that my answers are acurate

I have not answered honestly and understand that I will not be considered for entering treatment.

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