Screening Assessment

1

Patient Name* This field is required.

First Name

Middle Name

Last Name

2

Patient Date of Birth* This field is required.

3

Patient Gender* This field is required.

Male

Female

4

Submitted By: (Enter Name)* This field is required.

First Name

Last Name

5

Submitter E-mail* This field is required.

6

Phone Number* This field is required.

Area Code

Phone Number

7

Information Provided By:* This field is required.

8

Does Patient have a Legal Guardian?* This field is required.

Yes

No

9

If Yes, Guardian Name:

First Name

Last Name

11

If Other, Please Specify

12

Select Supportive Services that the Patient currently has:* This field is required.

Medication Management

PSR

ACTT Services

None

13

Is Family Actively in Patient's Life:* This field is required.

Yes

No

14

Does Patient have any pending court cases:* This field is required.

Yes

No

15

Is Patient on Probation or Parole:* This field is required.

Yes

No

16

Is Patient a Registered Sex Offender:* This field is required.

Yes

No

17

Is Patient Medicaid Active:

Yes

No

18

Does Patient have Special Assistance (SA):* This field is required.

Yes

No

19

Does Patient have Social Security (SI) setup:* This field is required.

Yes

No

20

Will the Patient funding source be Private Pay:* This field is required.

Yes

No

21

If Yes, How much per month:

22

Does Patient have a Rep Payee:* This field is required.

Yes

No

23

If Yes, Rep Payee Name:

First Name

Last Name

24

Does Patient have a Case Worker:* This field is required.

Yes

No

25

If Yes, Case Worker Name:

First Name

Last Name

26

Attach FL-2 and CCA

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