Prescreen Form for Inpatient Program and Intensive Outpatient Program
Please complete the form below to the best of your knowledge. Mandatory fields are marked with a (*). Once completed, the form will be directly sent to our Admissions Coordinator. Thank you for your time in completing the form.
Name (First and Last) *
Your answer
E-mail Address
Your answer
Phone Number *
Your answer
Social Security Number *
Your answer
Address (Street address, city, state and zip code) *
Your answer
Birthday
MM
/
DD
/
YYYY
Gender
Marital Status
What type of insurance do you have? *
Are you a veteran?
Do you receive any VA benefits?
Do you have a physical disability?
Are you on SSI or SSDI?
Do you have a valid driver's license?
What is your highest education level?
What is your current living situation?
Your answer
Drug/Alcohol History
Are you an IV drug user?
Is there drinking or drug use in your residence?
What is your drug (s) of choice?
How often? For how long?
Your answer
Date last used?
MM
/
DD
/
YYYY
Medical Information
Have you ever had a positive TB test?
Are you currently pregnant?
If you have any medical conditions or take any medications, please list them below. Please include how long you have had the condition or taken the medication.
Your answer
Have you been taking prescribed medications as ordered?
Psychiatric Information
Have you ever attempted suicide?
If yes, when?
Your answer
Have you ever had a psychiatric diagnosis?
If yes, please describe
Your answer
Are you taking any psychiatric medication?
If yes, what are you taking?
Your answer
Legal Information
Have you ever had a DUI?
If yes, how many?
Your answer
Do you have a pending court date?
If yes, for what? When? What county?
Your answer
Do you have a probation officer?
If yes, what is his/her name?
Your answer
Are you court referred for long-term treatment?
Treatment History
Have you been to a treatment facility before?
If yes, how many times have you been to treatment?
If yes, what facility?
Your answer
If yes, what was the date (s) of your stay (s)?
Your answer
Did you complete the treatment program?
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This form was created inside of Jackson Area Council on Alcoholism and Drug Dependency (JACOA).