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MARS-ATP Screening Form
DEMOGRAPHICS
Name
*
First Name
Last Name
Suffix
Email Address:
example@example.com
Date of Birth:
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Ok to leave voicemail?
*
Yes
No
Alternate Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Ok to leave voicemail?
Yes
No
Emergency Contact Name
*
Emergency Contact Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Ok to leave voicemail?
*
Yes
No
Gender:
*
Please Select
Male
Female
Other
Social Security Number:
Marital Status:
*
Please Select
Single
Never Married
Married
Divorced
Widowed
Separated
Cohabitating
Race:
Please Select
White
Black
Hispanic
Puerto Rican
Mexican
Bi-Racial
Asian
Middle-Eastern
Other
Employment:
Disability:
Were you referred?
Yes
No
If you were referred, by whom?
If you were referred, what is the best number to reach your referral source?
Health Insurance Carrier:
ID/Group Number:
Veteran of Armed Forces?
*
Yes
No
Veteran Status:
DRUG & ALCOHOL
-What substances(s) have you been using? When was your first use? What route are you using the substances? (oral/nasal/IV/IM/smoke)
How much and how often are you currently using?
IV Drug Use?
Yes
No
When?
Last use?
Are you experiencing any of the following withdrawal symptoms? (check all that apply)
Uncontrollable Shaking
Hallucinations
Seizures
Nausea/Vomiting
Severe Cramps
Other
Other (please specify):
Have you ever experienced any of the above symptoms?
Yes
No
If so, please explain:
Prior Drug & Alcohol Treatment?
Yes
No
Most recent facility:
When?
Type:
Mental Health
Are you currently having any thoughts of hurting yourself or others?
Yes
No
Suicide Plan:
Ability to contract for safety:
Yes
No
n/a
Plan to harm others?
Yes
No
Prior Mental Health treatment?
Yes
No
Most recent facility:
When?
Type:
Was medication prescribed?
Yes
No
If yes, explain (i.e. sleep, anxiety, etc.):
What medication do they have you taking and how often do you take it?:
PRENATAL/PERINATAL
Check here if none apply:
Does not apply
Are you pregnant?
Yes
No
Are you receiving prenatal care?
Yes
No
N/A
Given birth in the last 28 days?
Yes
No
N/A
Are you experiencing any complications that you feel may require emergent care?
Yes
No
N/A
If yes, explain:
REFERRAL FOR EMERGENT CARE SERVICES
**SCREENER**
Is there a need for a referral for emergent care services?
Yes
No
Reason:
If yes, where?
MEDICAL INFORMATION
Primary Care Physician:
PCP Phone:
Please enter a valid phone number.
Format: (000) 000-0000.
Current treatment by physician?
Yes
No
Current medications:
Last exam:
LEGAL
Involved with criminal justice?
Yes
No
Status:
Please Select
N/A
Pending
Probation
Parole
Pre-Trial
Parole/Probation Officer Name:
Parole/Probation Officer Phone:
Please enter a valid phone number.
Format: (000) 000-0000.
CYS Involvement?
Yes
No
Caseworker Name:
Caseworker Phone:
Please enter a valid phone number.
Format: (000) 000-0000.
Priority Populations/Special Needs
Check all that apply to you:
Pregnant IDU
Pregnant Substance User
IDU
Overdose
Adolescent
Woman with Children
Do you have any special needs?
Yes
No
If yes, please explain:
Availability for Assessment:
*
Please Select
Morning
Afternoon
Evening
Assessment Format:
*
Please Select
In Person
Virtual (Zoom)
If you do not receive a call back within 48 business hours please reach out to our intake department at 610-419-3101 ext 227
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