Pre-Entry Screen Form
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Date of Birth
-
Month
-
Day
Year
Date
Emergency Contact
First Name
Last Name
Relationship
Emergency Contact Phone Number
Please enter a valid phone number.
Referral?
Referral Phone Number
Please enter a valid phone number.
Referral Email
example@example.com
Current Treatments?
Anticipated Discharge Date?
-
Month
-
Day
Year
Date
Prior Treatments?
Recovery Residence History?
Drug(s) of Choice?
Any IV Opiate Use?
Yes
No
Sobriety Date?
-
Month
-
Day
Year
Date
Are you diagnosed with any medical or mental health condition, other than substance use disorder?
Are you receiving treatment for medical or mental health conditions, other than substance abuse disorder?
What medications are you prescribed (if any)?
Have you been a resident of Grandmaison Recovery in the past?
Yes
No
Do you have health insurance?
Yes
No
If yes, who is your carrier?
Do you have a history of self-harm?
Yes
No
Recent suicidal ideation?
Recent suicidal ideation?
Relationship status?
Do you have any children?
Yes
No
Work experience or plan?
Have you ever been arrested, convicted, or questioned for arson or any violent or sexual crimes?
Yes
No
Do you have any outstanding warrants?
Yes
No
Any legal issues?
Are you legally mandated to be here?
Yes
No
If yes, what is the legal charge?
Do you have a vehicle?
Yes
No
Do you have a valid license?
Yes
No
Any else you'd like to tell us?
Submit
Should be Empty: