Prescreen Admission Request Form Company Location and Referral Info Please select the facility you are interested in * Huntington (304) 523-4674 Bluefield (304) 800-4308 Charleston (681) 205-8589 Parkersburg (304) 428-6301 Her Place (304) 525-7686 Date of Referral Referred By Phone Number How did you hear about Recovery Point? Have you been a client here before? * Yes No If yes, when? Client Information Last Name * First Name * MI Phone Number Date of Birth * Social Security Number * Email Address Marital Status Single Married Race Age * Gender * Homeless? * Where did you live before coming to Recovery Point? * How long were you there? * Zip Code * Where are you from? (City, State) * County * Emergency Contact * Relation * Phone * Are you able to walk 5 miles/day and stand on your feet 30 hours per week? * Yes No Do you need assistance caring for yourself? * Yes No Do you have a history of seizures? * Yes No Severe withdrawal? * Yes No Are you pregnant? Yes No If yes, how long? Ae you experiencing a mental health crisis? * Yes No Have you ever been convicted of a violent crime? * Yes No Are you required to register as a sex offender? * Yes No Veterans What branch did you serve in? Dates of Service (mm/yy) Social Security Number Were you in combat? Yes No If so, where? Are you registered at a VA hospital? Yes No Current Medical Issues Do you have any doctors appointments in the next week? * Yes No If so, explain Developmental Disability? * Yes No If so, explain HIV/AIDS? * Yes No Hepatitis A/B/C? * Yes No Chronic Health Condition? * Yes No If so, explain * Are you a Domestic Violence Victim? * Yes No Are you currently fleeing a violent situation? * Yes No Protective Order? Yes No Physical Disability? * Yes No If so, explain Current Mental Health/Emotional Issues (Depression, Anxiety, Etc.) Any Past Diagnosis? * Yes No Past Psychiatric Hospitalizations? * Yes No Are you experiencing a mental health crisis today? * Yes No Do you have a mental health provider? * Yes No Who? Do you feel you need a mental health provider? * Yes No Medications How will you get your medications filled? Are there any medications you are prescribed but not taking? Yes No If so, which? Have you ever visited a Harm Reduction program? (needle exchange) Yes No Where? Do you have a Divers License or ID card? * Yes No Social Security Card? * Yes No Birth Certificate? * Yes No Do you have a High School diploma or GED? * Yes No Are you interested in obtaining your GED? Yes No Highest Level of Education? Justice System Involvement Are you a convicted felon? * Yes No Are you required by the courts or any other legal entity to enter this program? Yes No If so, what County? Who is the Judge? Probation or parole? PO’s Name Phone Number Are you Out on Bond? Yes No Court in the next week? Yes No Current criminal charges? Active warrant? Yes No Your lawyer’s name Phone Number DHHR and CPS Information How many children do you have? Do you have a CPS case? CPS Worker Name CPS Worker Phone Number County CPS Lawyer Name CPS Lawyer Phone Number Are you employed? * Yes No In the last 30 days, have you received any income? Yes No If yes, please list how much: SSI SSDI Veteran's Disability TANF Worker's Comp Child Support Other In the last 30 days, have you received any non-cash benefits? Yes No If so, how much? SNAP Medicaid Medicare CHIPS WIC VA Medical Services Section 8 / Public Housing Other Substance Use History Alcohol Date of Last Use Frequency of Use? Daily Weekly Rarely Avg. Amount used (grams) Cocaine Date of Last Use Frequency of Use? Daily Weekly Rarely Avg. Amount used (grams) Heroin Date of Last Use Frequency of Use? Daily Weekly Rarely Avg. Amount used (grams) Other Opiates Date of Last Use Frequency of Use? Daily Weekly Rarely Avg. Amount used (grams) Marijuana Date of Last Use Frequency of Use? Daily Weekly Rarely Avg. Amount used (grams) Methamphetamine Date of Last Use Frequency of Use? Daily Weekly Rarely Avg. Amount used (grams) Benzodiazepines Date of Last Use Frequency of Use? Daily Weekly Rarely Avg. Amount used (grams) Hallucinogens Date of Last Use Frequency of Use? Daily Weekly Rarely Avg. Amount used (grams) Synthetic Date of Last Use Frequency of Use? Daily Weekly Rarely Avg. Amount used (grams) Suboxone Date of Last Use Frequency of Use? Daily Weekly Rarely Avg. Amount used (grams) Form Submission 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. appcheckbox2 By checking this box and typing my name below, I am electronically signing my application. Full Legal Name * Sign on Behalf I have signed this application as an authorized representative on behalf of the applicant. Authorized Representative - Full Legal Name
304.523.4673
