Prescreen Admission Request Form Intake Form "*" indicates required fields Step 1 of 3 33% Location & Referral InformationPlease select the facility in which you are interested: Huntington (304) 5239-5104 Bluefield (304) 362-9795 Charleston (304) 759-8844 Parkersburg (304) 945-0255 The Point Apartments (304) 525-7686 Select AllDate of Referral MM slash DD slash YYYY Referred By: Phone Number How did you hear about Recovery Point? Have you been a resident here before?*YesNoIf yes, when? Have you ever been convicted of a violent crime?*YesNoAre you required to register as a sex offender?*YesNoHave you received a COVID-19 vaccination?*YesNoIf you have not received a COVID-19 vaccination, will you accept vaccination upon arrival?*YesNoResident InformationLast Name* First Name* MI Phone NumberDate of Birth* MM slash DD slash YYYY Social Security Number* Email Address Marital Status*SingleMarriedRace Age*Gender* Are you currently homeless?*YesNoWhere did you live before coming to Recovery Point?* How long were you there?* Where are you from? (City, State)* Zip Code* County* Emergency Contact* Relation* Phone Number*Are you able to walk 5 miles/day and stand on your feet 30 hours per week?*YesNoDo you need assistance with activities of daily living (bathing, feeding, dressing, etc.)*YesNoDo you have a history of seizures?*YesNoSevere withdrawal?*YesNoAre you pregnant?*YesNoIf yes, how long? Are you experiencing a mental health crisis?*YesNoVeteransIn which branch did you serve? Date of Service MM slash DD slash YYYY Are you registered at a VA hospital?YesNoWere you in combat?YesNoIf yes, where? Current Medical IssuesDo you have any doctors appointments in the next week?*YesNoIf yes, explain. Do you have a developmental disability?*YesNoIf yes, explain. HIV/AIDS?*YesNoHepatitis A/B/C?*YesNoChronic Health Condition?*YesNoIf yes, explain. Are you a Domestic Violence Victim?*YesNoAre you currently fleeing a violent situation?*YesNoProtective Order?*YesNoPhysical Disability?*YesNoIf yes, explain. Current Mental Health/Emotional IssuesAny Past Diagnosis?*YesNoPast Psychiatric Hospitalizations?*YesNoAre you experiencing a mental health crisis today (hearing voices, thinking of hurting yourself or others?)*YesNoDo you have a mental health provider?*YesNoWho? Do you feel you need a mental health provider?*YesNoAs a client of Recovery Point West Virginia, you will be required to have a mental health assessment by a Licensed Behavioral Health Center or other behavioral health provider, and you will be required to comply with the professional treatment recommendations that result from that mental health assessment. Do you agree to this requirement as part of the terms of your eligibility for the RPWV peer-to-peer program? BY ANSWERING YES, YOU ACKNOWLEDGE THAT YOU MAY BE DISCHARGED FROM THE PROGRAM IF YOU FAIL TO FOLLOW THE INSTRUCTIONS OF YOUR HEALTH PROVIDERS, INCLUDING ANY MENTAL HEALTH OR BEHAVIORAL HEALTH PROVIDER. Yes No MedicationsPlease list any medications, the reason for their use, and the dosage.How will you get your medications filled? Are there any medications you are prescribed but not taking?*YesNoIf yes, which? Have you ever visited a Harm Reduction program? (needle exchange)*YesNoIf yes, where? Do you have a Divers License or ID card?*YesNoSocial Security Card?*YesNoBirth Certificate?*YesNoDo you have a High School diploma or GED?*YesNoAre you interested in obtaining your GED?*YesNoHighest level of education?* Justice System InvolvementAre you a convicted felon?*YesNoAre you required by the courts or any other legal entity to enter this program?*YesNoIf so, what County? Who is the Judge? Probation or parole? PO’s Name PO's Phone NumberAre you Out on Bond?*YesNoCourt in the next week?*YesNoPlease list any current criminal charges. Do you have an active warrant?*YesNoIf you have one, please list your lawyer's name. Lawyer Phone NumberDHHR and CPS InformationIf you have children, how many? Do you have a CPS case?*YesNoIf yes, which county? CPS Worker Name CPS Worker Phone NumberCPS Lawyer NameCPS Lawyer Phone NumberAre you employed?*YesNoIn the last 30 days, have you received any income?*YesNoIf yes, please list how much:SSI SSDI Veteran's Disability TANF Workers' Comp Child Support Other In the last 30 days, have you received any non-cash benefits?*YesNoIf yes, please list how much:SNAP Medicaid Medicare CHIPS WIC VA Medical Services Section 8 / Public Housing Other Substance Use HistoryPast 12 MonthsAlcoholDate of Last Use MM slash DD slash YYYY Frequency of UseDailyWeeklyRarelyNoneAvg. Amount Used CocaineDate of Last Use MM slash DD slash YYYY Frequency of UseDailyWeeklyRarelyNoneAvg. Amount Used HeroinDate of Last Use MM slash DD slash YYYY Frequency of UseDailyWeeklyRarelyNoneAvg. Amount Used Other OpiatesDate of Last Use MM slash DD slash YYYY Frequency of UseDailyWeeklyRarelyNoneAvg. Amount Used MarijuanaDate of Last Use MM slash DD slash YYYY Frequency of UseDailyWeeklyRarelyNoneAvg. Amount Used MethamphetamineDate of Last Use MM slash DD slash YYYY Frequency of UseDailyWeeklyRarelyNoneAvg. Amount Used BenzodiazepinesDate of Last Use MM slash DD slash YYYY Frequency of UseDailyWeeklyRarelyNoneAvg. Amount Used HallucinogensDate of Last Use MM slash DD slash YYYY Frequency of UseDailyWeeklyRarelyNoneAvg. Amount Used SyntheticDate of Last Use MM slash DD slash YYYY Frequency of UseDailyWeeklyRarelyNoneAvg. Amount Used SuboxoneDate of Last Use MM slash DD slash YYYY Frequency of UseDailyWeeklyRarelyNoneAvg. Amount Used I have agreed to submit this application by electronic means. By signing this application electronically, I certify under penalty of perjury and false swearing that my answers are correct and complete to the best of my knowledge. I also certify that: - I understand the questions and statements on this application. - I have read and understand the legal information. - I understand the penalties for giving false information or breaking the rules. - I understand that an electronic signature has the same legal effect and can be enforced in the same way as a written signature.By checking this box and typing my name below, I am electronically signing my application. Full Legal Name I have signed this application as an authorized representative on behalf of the applicant. Authorized Representative - Full Legal Name
