Manning Recovery Center Self-Referral Screening Tool

Manning Recovery Center Self-Referral Screening Tool
Today's Date*

MonthDayYear
Date
Client Name*

First NameLast Name
Contact Person*

First NameLast Name
Contact Phone Number*
Please enter a valid phone number.
Client Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Client Phone Number*
Please enter a valid phone number.
Client DOB*
Birth Gender*

MaleFemaleDecline
Current Gender*

MaleFemaleOther
Reason/s Seeking Treatment Now*
Tell us why you are seeking treatment at this time, provide as much information as possible.
SSN
Insurance Provider*
Policy Number*
Policy Holder Name
Policy Holder Date of Birth
Client Employment*

UnemployedFull-timePart-timeOther
Client Email*
example@example.com
Medical History
Please list all medical issues*
Please check any relevant diagnosis

SeizuresPericarditisHistory of Brain injuryLiver Disease
Please list all Medications*
Have you been exposed to COVID-19 in the past 14 days?

YesNoUnknown
Any signs or symptoms of COVID right now?

CoughShortness of BreathLoss of taste or smellSevere HeadacheFever
Known Allergies*
All Previous Hospitalizations*
Is client Independent/Care of Self:*

YesNo
Ambulate on Own (can - walker - wheelchair)*

YesNo
Pancreatitis*

YesNo
Seizures*

YesNo
Special Needs/Accommodations Required:*

YesNo
Eating Disorder History*

YesNo
Please explain any accommodations needed:
Use History: Please be specific
Substance of Choice*
Date of Last Use*
Amount typically used*
How often are you using?*
What happens when you/they stop using?*
Ever needed Detox?*

YesNo
Previous Treatment*

InpatientOutpatientNone
Please list all substances used
Emotional History
Mental Health/Behavioral Issues*
Suicidal Ideation*

YesNo
If yes, what:
Suicidal Attempt*

YesNo
If yes, what:
History of Hallucinations*

YesNo
Schizophrenia*

YesNo
Bipolar*

YesNo
Psychologist/Therapist:*
Cognitive Difficulty*

YesNo
If yes, what:
Learning Disabilities*

YesNo
If yes, what:
History of Violence*
Other History
Pending Legal Issues*

YesNo
If yes, explain:
Civil Committal*

YesNo
If yes,*

Substance abuseMental Health
County*
Is the person on probation/parole?*

YesNo
Is the person under a substance abuse court order?*

YesNo
Is the person on the sex offender registry?*

YesNo
Anything else you want us to know?
Should be Empty:

Manning Recovery Center Self-Referral Screening Tool

Medical History

Use History: Please be specific

Emotional History

Other History