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*
Contact Phone #*
Format: (000) 000-0000.
Cell PhoneHome PhoneWork Phone
Email Address*

Confirmation Emailexample@example.com
Who is completing these forms for this youth?
Mental HealthDrug and Alcohol AbuseTherapyOutpatient Substance Abuse TreatmentMedicationIn-Patient Substance Abuse Treatment (Genesis)Anger ManagementDetox/Withdrawal Management
YesNo
Name of Insurance
Name of Insurance
YesNo
YesNo
YesNo
YesNo
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)
YesNo
Please Describe
NoneArsonRegistered Sex OffenderFelonious AssaultDUI/OVIManslaughterDomestic ViolenceOther Legal Issues: (Please Describe)
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
Alaska NativeAmerican IndianAsianBlack or African AmericanWhite/CaucasianPacific IslanderTwo or more racesOther Specific Race (Please list)
Not of Hispanic OriginUnknownCubanMexicanPuerto RicanOther Specific Hispanic(Please list)
What is your primary language, if not English?
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
Schedule an Assessment (In-person/Virtual/Video)Walk-in (In-person)
Should be Empty:

Pre-Screening