Demographics
Name
*
First Name
Middle Initial
Last Name
Last name at birth
*
Phone Number
*
-
Area Code
Phone Number, enter all 9s if no phone
Email
example@example.com
Physical Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mailing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth:
*
-
Month
-
Day
Year
SSN:
Gender:
*
Female
Male
Other
Race:
*
African American
Alaska Native
American Indian
Asian
Caucasian
Native American
Native Hawaiian or Pacific Islander
Other Single Race
Pacific Islander
Two or more unspecified races
Ethnicity:
*
Cuban
Hispanic
Mexican
Not of Hispanic Origin
Other Specific Hispanic
Puerto Rican
Unknown
Marital Status:
*
Divorced
Married
Separated
Never Married
Widowed
Single
Tobacco User:
*
User
Non User
Smoker status:
*
Current smoker
Former smoker
Never smoked
Language Preferred:
*
English
Spanish
Need Interpreter:
*
Yes
No
Military Status:
*
Yes
No
Employment status:
*
Full Time (35+ hours/week)
Part Time (Under 35 hours/week)
Unemployed
Homemaker
Student
Retired
Disabled
Occupation:
Education level:
Highest level achieved
Why are you seeking treatment at this time?
*
Referral Source:
*
Probation/Federal Probation
DUII
State Agency – DHS Child Welfare
Self – Volunteer
Mental Health Other / Substance Abuse
Physician – Dr. Grenwald / Dr. Quade
Other: ATI / La Clinica / Oasis Center / Redemption Ridge / Other
Probation / Case Worker Name
Annual income:
Primary Source of Income:
*
Wages/Salary
Public Assistance
Retirement/Pension/SSI
Disability/SSDI
Other
None
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Additional information required by the State.
Total number of dependents (including self):
Number of child dependents:
Pregnant:
*
Yes
No
Expected source of payment:
*
Self-Pay
Medicaid/OHP
Private Health Insurance
Living Arrangement:
*
Other private residence
private residence (at home)
private residence (with relatives)
private residence (non-relatives)
transient/homeless
foster home
jail
oxford house
alcohol/drug free housing
Drivers License Number:
Indicate state if not Oregon
Referral from:
*
ADES (DUII)
Child Welfare
Circuit Court
Federal Court
Parole
Probation
Self
Tribal Affiliation:
*
Not Applicable
Burns Paiute Tribe
Conf. Tribes of Coos, Lower Umpqua & Siuslaw
Conf. Tribes of Grand Ronde
Conf. Tribe of Siletz
Conf. Tribes of the Umatilla
Conf. Tribes of Warm Springs
Coquille Indian Tribe
Cow Creek Band of Umpqua
Klamath Tribes
Other
Have you used alcohol or drugs within the last 90 days?
*
Yes
No
Number of arrests in the past month:
Total lifetime arrests:
Number of DUII in the past month:
Total lifetime DUII arrests:
How many times have you attended a support group in the past 30 days?
Example: A.A., N.A., SMART Recovery, Al Anon, Gamblers Anonymous, etc.
Total number of positive Alcohol/Drug tests in past 30 days?
How did you hear about Phoenix Counseling Center?
Submit
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