Name
First Name
Last Name
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.
Email
example@example.com
Social Security Number
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age
Referral Source
Referral Reason
* Payment is required at the time of services, $25 fee for returned checks or credit card payments. If paying by check, assessment results will not be forwarded until the check clears. How are you paying today?
Cash
Check
Visa or MasterCard
Other or EAP (Please specify name of Company)
Health Insurance? If Yes, please specify. *If using health insurance, please complete the red & white insurance claim form.
Gender
Male
Femaile
Other (Please specify)
Racial Ethnic Group
American Indian or Alaskan Native
African American or Black
Asian
Native Hawaiian or Pacific Islander
Caucasian
Other (Please specify)
Relationship Status
Single
Married
Divorced
Separated
Dating
Never Married
Other
Employment Status
Full Time
Part Time
Unemployed
Full or Part Time Student
DWI, Court Ordered, Pre-Trial, or Probation Referrals Only:
List any pending legal charges
Attorney or PO Contact Name:
First Name
Last Name
Attorney or PO Contact Email:
example@example.com
Attorney or PO Contact Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Do you need a letter for your attorney or PO?
Yes
No
DWI cases, can you provide copies of your BAC, ticket, and driving record?
Yes
No (Please specify why)
Have you ever had a license in another state? If so, what states?
Are you able to get a driving record in other states you have lived?
What has been done to pertain all of client's driving records?
Have you ever been diagnosed, treated for, or have a history of any of the following (check all that apply)
Addiction
Psychiatric Hospitalization
Suicide Attempts
Visual Impairment
Hearing Impairment
Speech Impairment
Threatened/Harmed others
Other
Do you verify there are no physical limitations that will prohibit you being safe at MTS, Inc.?
Yes
No (Please specify)
Are you currently involved in high-risk behaviors that compromise safety/health?
Yes
No (Ex. Unprotected sex, criminal behavior, needle sharing, excessive use of alcohol or drugs) Please specify
Emergency Contact Information
Contact's Name
First Name
Last Name
Relationship to Contact
Contact's Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Contact's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Nearest Relative (Name, Address and Phone Number)
Preferred Hospital
I hereby certify that the health information I have given to be true to the best of my knowledge.
Client Signature
Submit
Should be Empty: