Clone of Pre-Screening Questionnaire

1627 N SWAN RD STE 101; TUCSON, AZ 85712

SUNLIGHTDESK@GMAIL.COM
Pre-Screening Questionnaire

Thank you for your interest in receiving services at Sunlight Center for Change (SCC). Please answer the following screening questions completely and accurately. These should be submitted to the SCC office as quickly as possible. If you have any technical difficulties with this form or require special accommodations, please request this questionnaire in either PDF or paper format from our office.
Both parties must complete this form and respond to all questions.

You are responsible for notifying SCC in writing within 24 hours if any information contained herein changes.
Your Name:*

First NameLast Name
Phone Number:*
Please enter a valid phone number.
Email:*
example@example.com
Today's Date:*

MonthDayYear
Date
Please list any acute or chronic health issues for anyone involved in services (you or the children):*
1. Clinicians must speak the language the clients will speak at meetings. Services at SCC are currently only offered in English. Is your family willing and able to speak English at all times during the meetings?*

YesNo
2. List the name and age of each child who will be participating in the process if applicable:*
Name of the co-parent OR other party:*

First NameLast Name
3. Is there any current Restraining Orders/Orders of Protection? If yes, please upload a copy of the Order.*

YesNo
File Upload

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4. Were there any past Restraining Orders/Orders of Protection between any of the parties on this case? Please answer "Yes" or "No." If yes, please explain below.*
5. Have there ever been any domestic violence incidents? Please answer "Yes" or "No." If yes, please explain below.*
6. Is there a domestic violence history between you and any person other than the other party in this case? Please answer "Yes" or "No." If yes, please explain below.*
7. Is there a domestic violence history between the other party and any other person? Please answer "Yes" or "No." If yes, please explain below.*
To your knowledge, how long ago did that incident occur, if applicable?*
8. For the children involved in this case, has either party had any past involvement with a child welfare agency (example DCS, CPS, Tribal, etc) to include investigation into abuse/neglect allegations, case management services etc? Please answer "Yes" or "No." If yes, please explain below.*
9. For any children involved in this case, are there any currently open investigations or case management services with a child welfare agency (example DCS, CPS, Tribal, etc)?*
10. Has either parent been charged with or currently under investigation for a crime that involved a child on this case? Please answer "Yes" or "No." If yes, please explain below and state which parent/parents are involved.*
11. Are there any formal allegations of a sexual nature, between a child and a parent on this case, that are currently under investigation or that were previously investigated? Please answer "Yes" or "No." If yes, please explain below. For investigations that are closed, please explain the outcome.*
12. Do you have a criminal history? Please answer "Yes" or "No." If yes, please explain below to include information regarding any convictions and any currently pending cases/charges:*
13. Does the other parent have a criminal history? Please answer "Yes" or "No." If yes, please explain below to include any known information regarding any convictions and any known pending cases/charges:*
14. Are you currently on probation/parole/work release/home arrest/monitored release? Please answer "Yes" or "No." If yes, which?*
15. Is the other parent currently on probation/parole/work release/home arrest/monitored release? Please answer "Yes" or "No." If yes, which?*
16. Do you have a condition of release/probation that limits or prohibits contact with the other parent, the child(ren), or any person you potentionally could come into contact with during the supervision? Please answer "Yes" or "No." If yes, please list.*
17. Do you have a condition of release that would require SCC to verify your appointments at SCC, require additional paperwork or that limits the hours/days you are able to attend appointments? Please answer "Yes" or "No." If yes, please explain below.*
18. Are you required to register as a sex offender? Please answer "Yes" or "No." If yes, please explain in what state the crime occurred below and upload documentation about this offense at the end of this form.*
19. Is the other parent required to register as a sex offender? Please answer "Yes" or "No." If yes, please explain in what state the crime occurred below and upload documentation about this offense at the end of this form.*
20. Do you have a history of alcohol/substance abuse? Please answer "Yes" or "No." If yes, please explain below.*
21. Does the other parent have a history of alcohol/substance abuse? Please answer "Yes" or "No." If yes, please explain below.*
22. Would you require any special accommodation in order to receive services at SCC? Please answer "Yes" or "No." If yes, please explain below. (for example, a personal health aide attending with you, etc)*
23. Would any of the children require any special accommodation in order to receive services at SCC? Please answer "Yes" or "No." If yes, please explain below.*
24. Do you have any medical conditions we should know about that could interfere in your services at SCC? Please answer "Yes" or "No." If yes, please explain below.*
25. Would any child need medical treatment for a chronic condition or the administration of a medication during the time they would be at SCC? Please answer "Yes" or "No." If yes, please explain below. (for example, asthma inhalers, diabetic testing and treatment, etc)*
26. Please describe which services are being requested and why services are being sought below.*
27. For the sought service, please describe the frequency, length, and any specific days/times named in a Court Order or Parenting Plan:*
28. Have you ever received supervised services in the past for the children involved in this case either at SCC or another agency? Please answer "Yes" or "No." If yes, please explain below to include: the services that were received, providing agency, dates of service and the reason services ended.*
29. Is there a Parenting Plan? Please answer "Yes" or "No." If yes, you must upload it or provide a copy to the office. Please explain below if the plan is being adhered to and if not, what the variance is at this time.*
File Upload

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30. How often does the child/children see you? Please describe below the frequency of contact, the type of contact (phone, mail, in person supervised or unsupervised, etc), and if the contact was required to be supervised.*
31. How often does the child/children see the other parent? Please describe below the frequency of contact, the type of contact (phone, mail, in person supervised or unsupervised, etc), and if the contact was required to be supervised.*
32. Please describe the type and frequency of contact between the child/children and you over the child/children's lifetime.*
33. Please describe the type and frequency of contact between the child/children and the other parent over the child/children's lifetime.*
34. Is there a history of physical abuse/neglect/verbal abuse/emotional abuse/sexual abuse between you and the child/children? Please answer "Yes" or "No." If yes, please describe below.*
35. Is there a history of physical abuse/neglect/verbal abuse/emotional abuse/sexual abuse between the other parent and the child/children? Please answer "Yes" or "No." If yes, please describe below.*
36. Are you currently in therapy?*

YesNo
Therapist Info:

First NameLast Name
Therapist Phone #
Please enter a valid phone number.
Therapist Email:
example@example.com
37. Have you been in therapy in the past or hospitalized for mental health reasons? Please answer "Yes" or "No." If yes, please provide the name(s) and contact information for the treatment provider(s):*
38. List any mental health medications you are currently on below. You must include the dosage and the prescriber's name and contact information.*
39. List any mental health medications you have been on in the past below. You must include the dosage and the prescriber's name and contact information.*
40. Is the other parent currently in therapy? If yes, list if you know where.*
41. Have the other parent been in therapy in the past or hospitalized for mental health reasons? Please answer "Yes" or "No." If yes, please provide the name(s) and contact information for the treatment provider(s) if known:*
42. List any mental health medications you believe that the other parent is currently on below. If known, please include: the dosage and the prescriber's name and contact information.*
43. List any mental health medications you believe that the other parent has been on in the past below. If known, please include: the dosage and the prescriber's name and contact information.*
Is the child/children currently in therapy?*

YesNo
Child's therapist name:

First NameLast Name
Child's therapist phone number:
Please enter a valid phone number.
Child's therapist email:
example@example.com
45. Has the child/children been in therapy in the past or hospitalized for mental health reasons? Please answer "Yes" or "No." If yes, please provide the name(s) and contact information for the treatment provider(s) if known:*
46. Please provide any additional information in the space below that you believe is important.*
47. Please upload a copy of any other documents you believe would be important to have on file for your case:

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By signing below, you agree that the statements you made herein are complete and accurate. Failure to provide complete and accurate information could result in services being denied or being terminated at a later date.
Signature*

Clear
Printed Name:*
Date:*

MonthDayYear
Date
Should be Empty:

1627 N SWAN RD STE 101; TUCSON, AZ 85712

Pre-Screening Questionnaire

Both parties must complete this form and respond to all questions.