MPW Pre-Screen Form (Official) Website Version

Pre-Screening
Age
Today's Date*

MonthDayYear
Date
Hour MinutesAM/PM Option
Name*

First NameMiddle InitialLast Name
Preferred Name:
Birth Sex*
Required for Health Insurance
My Pronouns:
Optional
Current Gender Identity:
Date of Birth: (mm/dd/yyyy)*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState

Zip Code
County*
Cell Phone #*
Home Phone #
Email Address*

Confirmation Emailexample@example.com
Who is completing these forms for this youth?
What service are you interested in? (Check all that apply)*

Mental HealthDrug and Alcohol AbuseTherapyOutpatient Substance Abuse TreatmentMedicationIn-Patient Substance Abuse Treatment (Genesis)Anger ManagementDetox/Withdrawal Management
Do you have Insurance?*

YesNo
Name of Insurance
Are you homeless?*

YesNo
Are you court ordered?*

YesNo
Are you suicidal?*

YesNo
Are you considering harming or killing another person?*

YesNo
Medical Issues (Check all the apply)*

NoneAcute Hepatitis (Hepatitis A)History of confusion while in a medical detox settingUntreated Seizure Disorder or history of seizuresCurrent PICC Line or IVDialysisFemales: chance of pregnancyMobility Problems (Use of crutches, walker, wheelchair, etc.)Oxygen useChest pains or Heart DiseaseActive outbreak of Shingles or Chicken PoxInsulin Dependent DiabeticOther Medical Issues: (Please Describe)
Have you been hospitalized in the last 48 hours?*

YesNo
Please Describe
Legal Issues (Check all that apply)*

NoneArsonRegistered Sex OffenderFelonious AssaultDUI/OVIManslaughterDomestic ViolenceOther Legal Issues: (Please Describe)
How did you hear about MPW? (Check all that apply)*

Friend/FamilyPrimary Care DoctorEmployee of MPWCourt/LawyerSocial media (FB, Instagram, TikTok, LinkedIn)Web Search (Google, Bing, etc.)Other
If Other, please enter how you heard about MPW
What is your race? (Check all that apply)*

Alaska NativeAmerican IndianAsianBlack or African AmericanWhite/CaucasianPacific IslanderTwo or more racesOther Specific Race (Please list)
What is your ethnicity? (Check all that apply)*

Not of Hispanic OriginUnknownCubanMexicanPuerto RicanOther Specific Hispanic(Please list)
What is your primary language, if not English?
SMOKING STATUS? (Check all that apply)*

Current EverydayCurrent Some daysFormer SmokerNever Smoke
IF YOU ARE IN DANGER OF HARMING YOURSELF OR SOMEONE ELSE, PLEASE GO IMMEDIATELY TO THE NEAREST HOSPITAL OR CALL 911

Pre-Screening