Prescreen Admission Request Form

Intake Form

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Step 1 of 3

Location & Referral Information

Please select the facility in which you are interested:
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Resident Information

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Current Medical Issues

Current Mental Health/Emotional Issues

As 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.
Please list any medications, the reason for their use, and the dosage.

Justice System Involvement

DHHR and CPS Information

If yes, please list how much:

If yes, please list how much: