Prescreen Application
This client intake form is used to gather information necessary to determine if an individual qualifies for treatment and/or housing through Cairn Recovery Resources. Please fill this out fully to the best of your ability before submitting. Once reviewed, we will contact you at the number provided.
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Email *
Todays Date: *
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Is this a professional referral? *
Gender
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If so, please provide name, agency and contact here
Is this a self referral?
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If yes, how did you hear about Cairn?
Name: *
Date:
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Birthdate *
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Address:
Phone number:
Social Security Number: *
Marital Status
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Do you have Ohio Medicaid?
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Medical Insurance Provider: 
Insurance ID number:
Services Requested *
Required
Are you currently in treatment or another program? If so, please list where and anticipated discharge date.
Have you been a Cairn client before?
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Reason for requesting services: *
Are you currently receiving medication assisted treatment (MAT)? This includes Methadone, Suboxone, Vivitrol, etc.  *
Do you have any current mental health diagnosis? 
Are you experiencing any withdrawal symptoms? If yes, please explain.
Substance Use History: Please list alcohol or name of substances used, frequency of use for each substance, and dates of last use. Ex: Alcohol, 4 days a week, last use January 12th, 2025.
Do you have a history of diabetes?
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If yes, how do you independently manage your symptoms?
History of seizures or cancer?
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If yes, are you currently prescribed medication to manage symptoms?
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Do you require oxygen or any other medical devices?
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If yes, which device? If oxygen is required, how many liters?
Do you currently have any open wounds or tubing?
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Any known medical issues or concerns not already mentioned? If yes, please explain.
Are you able to independently manage daily medications and follow medical orders?
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Are you currently pregnant?
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If yes, how far along is your pregnancy?
Please list all medications you are currently taking along with dosage for each
Have you had any hospital stays or urgent care visits in the last 90 days?
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Are you capable of completing all ADL's such as feeding, clothing and bathing yourself without assistance or reminding?
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Are you able to climb stairs, get into a bathtub, or into a van without assistance?
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Do you have any mobility issues that require a walker, crutches, wheelchair, etc.?
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Are you currently having any suicidal or homicidal thoughts?
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Have you ever attempted suicide?
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If yes, please provide date of attempt and if any professional treatment was received afterward.
Are you currently on probation or parole?
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If yes, what for and for how long?
Probation officers name and contact info:
Do you have any open CPS (Child Protective Services) cases? If yes, please explain.
Have you ever been convicted of a sexual crime?
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Have you ever been convicted of arson?
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Have you ever been convicted of a violent crime?
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Please list all conviction and specifications:
Do you have any active warrants at this time?
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Do you have any upcoming court dates?
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If accepted into this program, will you be needing transportation to our agency?
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