Screening / Application

Screening / Application
Today’s Date:

Month Day Year
Select Your Clinic:
Print Full Legal Name
List any aliases:
Who referred you to our program?
Date of Birth
Social Security #:
Address:
Street, City, State, Zip Code
Telephone Number(s):
Home Phone #:
Cell #:
Business #:
Hawai’i Resident?
If yes, for how long have you been a resident of Hawai'i?
Ethnicity:
Medical Insurance?
Type:
Do you use Nicotine?
If yes, do you SMOKE, CHEW, or VAPE?
Martial Status
U.S. Military Status:
If yes, type of discharge:
Branch:
Emergency Contact - Name:
Relationship:
Home #:
Work#:
Cell#:
Address:
EDUCATION / EMPLOYMENT
Highest grade completed:
G.E.D.?
Name of High School Last Attended:
College?
If yes, the number of years completed and major:
Training or Technical education?
Presently employed or Self employed?
If yes, what type of work?
Where?
Student?
If yes, where?:
How long was your longest full time job?
Usual Occupation:
Do you possess any special skills?
Current family income per month:
Currently on welfare?
I have been receiving Welfare in the amount of:
Monthly amount
and food stamps in the amount of:
Monthly amount
Currently receiving Social Security?
If yes, in the amount of:
Monthly amount
Currently receiving Temporary Disability Insurance?
If yes, in the amount of:
Monthly amount
EDUCATION / EMPLOYMENT Continued:
Currently receiving Unemployment Benefits?
If yes, in the amount of:
Monthly amount
Are you currently receiving any other type of monetary assistance?
If yes, who from?
If yes, in the amount of:
Monthly amount
How many days have you experienced employment problems in the past 30 days?
How troubled or bothered have you been by these employment problems in the past 30 days? (select one)
How important to you now is counseling for these employment problems?
Comments:
MEDICAL INFORMATION:
Are you pregnant?
If yes, how many months?
Have you ever been hospitalized?
If yes, how many times?:
When was the last time?
Date
What for?:
List all medical complications:
List all medications presently prescribed:
List all medications prescribed in the past:
When was your last physical exam?
Date
When was your last TB Test:
Date
Are you allergic to any type of medication?
If yes, please explain:
Do you have any allergies to foods, insect bites, plants, animals, etc?
If yes, please explain:
Any Medical Insurance?
If yes, coverage is with:
Name of insurance provider
Medical record #:
How many days have you experienced medical problems in the past 30 days?
How troubled or bothered have you been by these medical problems in the past 30 days?
How important to you now is treatment for these medical problems?
Comments:
LEGAL:
Have you ever been arrested?
If yes, what are the charges, dates, and outcome:
For each legal charge, please include the date of arrest and conviction (if applicable), and outcome
Are you presently awaiting trial or sentencing?
If yes, what for?
And, date of next hearing:

Month Day Year
Date
Are you under any of the following?
If yes, how long:
Were you ever incarcerated?
If yes, longest length of incarceration?
What were the charges?
How many days have you experienced legal problems in the past 30 days?
How troubled or bothered have you been by these legal problems in the past 30 days?
How important to you now is counseling for these legal problems?
Comments:
PSYCHOLOGICAL:
Have you ever been treated for any psychological problems or diagnosis?
If yes, explain:
Are you presently being treated for psychological or emotional challenges?
If yes, by whom?
List all medications being prescribed:
Have you ever experienced any thoughts of suicide?
If yes, when was the last time?
Have you ever attempted suicide?
If yes, how many times?
When was the last time?
How did you attempt at that time?
Have you ever experienced any thoughts of homicide?
If yes, when was the last time?
Have you ever experienced serious depression?
If yes, explain:
Do you feel safe at home?
If no, explain:
Have you ever experienced trouble understanding, concentrating, or remembering?
PSYCHOLOGICAL Continued:
Is there a history of mental health challenges or diagnosis in your family?
If yes, explain:
How many days have you experienced psychological problems in the past 30 days?
How troubled or bothered have you been by these psychological problems in the past 30 days?
How important to you now is treatment for these psychological problems?
Comments:
FAMILY / SOCIAL:
Current living arrangements with:
How long?
Are you satisfied living there?
Do you live with anyone with an alcohol or drug problem?
If yes explain:
Are you in a romantic relationship?
If yes, how long?
Are you satisfied?
Explain why or why not:
How many friends or family are of support to you for your recovery?
Who are they?
Do you practice any spiritual, cultural or religious activities?
If yes, please explain?
Are you experiencing any type of family or social problems?
If yes, explain:
Is there any history of illegal drug or alcohol use in your family?
If yes, please give a brief history:
Have you ever been emotionally abused?
Have you ever been sexually abused?
Have you ever been physically abused?
Comments:
FAMILY/SOCIAL Continued:
How many days have you experienced problems getting along with family in the past 30 days?
Explain:
How troubled or bothered have you been by these family problems in the past 30 days?
How important to you now is counseling for these family problems?
How many days have you experienced problems getting along with friends in the past 30 days?
Explain:
How troubled or bothered have you been by these social problems in the past 30 days?
How important to you now is counseling for these social problems?
ALCOHOL / DRUG HISTORY:
(A) Begin with your substance of choice

(B) Secondary substance of choice

(C) Third substance of choice
(A) Substance Used:
(A) Date First Used:

Month Day Year
Date
(A) Frequency Used:
(A) Amount:
(A) Regular amount used:
(A) Frequency:
(A) Amount:
(A) Date Last Used:

Month Day Year
Date
(A) Effects of Use:
(B) Substance Used:
(B) Date First Used:

Month Day Year
Date
(B) Frequency Used:
(B) Amount:
(B) Regular amount used:
(B) Frequency:
(B) Amount:
(B) Date Last Used:

Month Day Year
Date
(B) Effects of Use:
(C) Substance Used:
(C) Date First Used:

Month Day Year
Date
(C) Frequency Used:
(C) Amount:
(C) Regular amount used:
(C) Frequency:
(C) Amount:
(C) Date Last Used:

Month Day Year
Date
(C) Effects of Use:
Comments:
PREVIOUS SUBSTANCE ABUSE TREATMENT:

Treatment Program Provider

	Treatment Provider Name/Facility	Dates	Outcome
Treatment Provider 1
Treatment Provider 2
Treatment Provider 3
Treatment Provider 4

How many days have you experienced Drug problems in the past 30 days?
How troubled or bothered have you been by these Drug problems in the past 30 days?
How important to you now is treatment for these Drug problems?
How many days have you experienced Alcohol problems in the past 30 days?
How troubled or bothered have you been by these Alcohol problems in the past 30 days?
How important to you now is treatment for these Alcohol problems?
In the space provided below, please list:
Strengths:
Needs:
Abilities:
Preferences:
How many Social Support Meetings i.e, AA or NA Meetings, Spiritual, Cultural Gatherings etc have you attended in the past 30 days:
Applicant Signature

Clear
Date

Month Day Year
Date
Counselor Signature

Clear
Date

Month Day Year
Date
Date

Month Day Year
Date
Should be Empty:

Screening / Application

Telephone Number(s):

EDUCATION / EMPLOYMENT

MEDICAL INFORMATION:

LEGAL:

PSYCHOLOGICAL:

PSYCHOLOGICAL Continued:

FAMILY / SOCIAL:

FAMILY/SOCIAL Continued:

ALCOHOL / DRUG HISTORY:

PREVIOUS SUBSTANCE ABUSE TREATMENT: