Manning Recovery Center Self-Referral Screening Tool
Today's Date
*
-
Month
-
Day
Year
Date
Client Name
*
First Name
Last Name
Contact Person
*
First Name
Last Name
Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Client Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Client Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Client DOB
*
Birth Gender
*
Male
Female
Decline
Current Gender
*
Male
Female
Other
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
*
Unemployed
Full-time
Part-time
Other
Client Email
*
example@example.com
Medical History
Please list all medical issues
*
Please check any relevant diagnosis
Seizures
Pericarditis
History of Brain injury
Liver Disease
Please list all Medications
*
Have you been exposed to COVID-19 in the past 14 days?
Yes
No
Unknown
Any signs or symptoms of COVID right now?
Cough
Shortness of Breath
Loss of taste or smell
Severe Headache
Fever
Known Allergies
*
All Previous Hospitalizations
*
Is client Independent/Care of Self:
*
Yes
No
Ambulate on Own (can - walker - wheelchair)
*
Yes
No
Pancreatitis
*
Yes
No
Seizures
*
Yes
No
Special Needs/Accommodations Required:
*
Yes
No
Eating Disorder History
*
Yes
No
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?
*
Yes
No
Previous Treatment
*
Inpatient
Outpatient
None
Please list all substances used
Emotional History
Mental Health/Behavioral Issues
*
Suicidal Ideation
*
Yes
No
If yes, what:
Suicidal Attempt
*
Yes
No
If yes, what:
History of Hallucinations
*
Yes
No
Schizophrenia
*
Yes
No
Bipolar
*
Yes
No
Psychologist/Therapist:
*
Cognitive Difficulty
*
Yes
No
If yes, what:
Learning Disabilities
*
Yes
No
If yes, what:
History of Violence
*
Other History
Pending Legal Issues
*
Yes
No
If yes, explain:
Civil Committal
*
Yes
No
If yes,
*
Substance abuse
Mental Health
County
*
Is the person on probation/parole?
*
Yes
No
Is the person under a substance abuse court order?
*
Yes
No
Is the person on the sex offender registry?
*
Yes
No
Anything else you want us to know?
Submit
Should be Empty: