CLARKSBURG MISSION INTAKE ASSESSMENT
Potential Resident Name
*
First Name
Last Name
Birth Date
*
-
Month
-
Day
Year
Date
Social Security Number
*
Current Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Contact Name (If different than applicant)
*
First Name
Last Name
Emergency Contact & Release of Information (Full name, address, phone and relationship)
*
*l understand that the person listed above will be given any information deemedappropriate by management, in the event that it is necessary to communicatewith them during my stay in this facility
Current Treatment Information
Current Treatment Center or Correctional Facility
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Primary Counselor
*
Counselor Contact Number
*
Please enter a valid phone number.
Tentative Discharge Date
*
Past Treatment Programs
*
Substances Used in the Past
*
Drug(s) of Choice
*
Clean Date
*
lncome and Legal lnformation
Current Source of Income
*
Weekly $
*
Pending Legal Matters (Please explain)
*
Past Legal Matters (Please explain)
*
Are you required to register as a sex offender?
*
Yes
No
Do you have any mental health diagnoses?
*
Yes
No
If "Yes", please explain
Do you have any physical limitations?
*
Yes
No
If "Yes", please explain
Medical lnformation
Current Medication and Dosages:
Miscellaneous
How did you hear about us?
*
Applicant's Name
First Name
Last Name
Applicant's Signature
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: