SOS Intake

Intake Questionaire

Please fill out this form to request services or schedule an appointment.
Date of Intake

MonthDayYear
Date
Intake Specialist Name
OCR Autofill
Type of Health Service
Full Name

First NameLast Name
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Alternate Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Date of Birth

MonthDayYear
What was the highest level of education you completed?
Gender
Pronouns

Other
Race

Other
Religion
Marital Status
Sexual Orientation

Other
Insurance Type
What are your primary goals for joining the DCG?

Other
What is your current housing accommodation status?
Employment Status

Other
Have you ever had a mental health diagnosis? If yes, what was your diagnosis? Are you currently receiving mental health services? If so, your mental health diagnosis?
Have you ever had a mental health diagnosis?
What was your diagnosis?
Are you currently receiving mental health services?
If so, what is your current diagnosis?
Are you currently receiving PRP Services?
Describe Symptoms/Risk Behaviors
Other: If yes, where? Leave blank if you prefer not to disclose.
.
Do you hear voices or see strange things?

Other
Do you have delusions?

Other
Are you depressed (Thoughtful, worried, lack of interest?)

Other
Are you anxious or overwhelmed?

Other
Do you hate socializing with others
Do you have anger outbursts?
Do you have sleep problems?
Do you have anxiety or panic attacks?
Do you self-injure?

Other
Have you experienced trauma?
If yes, what type of trauma
Brief description
Have you ever been Suicidal or Homicidal thoughts?
If yes, please give approximate date of suicidality.homicidality and brief description.
Do you have trouble with the following Activities of Daily Living?

Other
Are you currently receiving any Medication?
If yes, what medications are you currently taking?
Do you have any physical health condition?

Other
Please describe any experiences of life-threatening illness.
Do you need assistance accessing primary care services?
Do you have a primary care doctor?

Other
Are you currently experiencing any pain?
If yes, on a scale of 0-10, how would you rate your pain level?

Other
Have you ever been incarcerated?

Other
if yes, how long have you been incarcerated?
Do you currently have legal issues?

Other
If yes, please explain
Do you have brothers and sisters?

Other
Do you have kids?

Other
Do you have a support Network? (Church, Voluntary activities etc)
Do you use any substances (e.g., alcohol, tobacco, drugs, heroine, crack, k12, pcp, marijuana etc)?
If yes, what is your substance(s) of choice?
Would you like assistance with substance use/abuse recovery?
Have you ever experienced community violence (e.g., shootings, robbery, burglary, bullying, assault)?
Please describe:
Is transportation a barrier?
Please list any additional information that you would like to share.
Upload a copy of the front and back of your ID

Please upload clear images or a PDF of the front and back of your ID.
Cancelof
Upload a copy of the back and front of your insurance card

Please upload clear images or a PDF of the front and back of your insurance card.
Cancelof
Take a photo of the front of your ID
Take a photo of the back of your ID
Take photo of the front of your Insurance card
Take photo of the back of your insurance card
Should be Empty:

Intake Questionaire