Intake Screening Form – ABC Men's Recovery Residence

Resident's Name *

First

Last

Resident's Email *

Resident's Phone *

Resident's Mailing Address *

Address Line 1

City

State

Zip Code

Resident's Age *

Resident's Date of Birth *//

Resident's Gender *

Is resident able to pay for housing at this time? *

Is resident able to pay the $150 deposit? *

Can resident speak, write and understand English? *

Why is the resident seeking housing at this time? *

What strengths does the resident possess? *

What preferences does the resident have? *

What goals does the resident have? *

Date of resident's last physical health screening (can be approximate) *//

What was the outcome of the last physical health screening? *

Do you have a history or diagnosis of an eating disorder? *

Date of residents last use of drugs/alcohol (can be approximate) *//

Does resident need detox before admittance? *

Does resident have any disabilities that could affect participation in housing (deaf, blind, etc.)? *

Does resident have any prior psychiatric history (please explain)? *

Resident must be stable prior to starting treatment and can not be actively suicidal, homicidal or psychotic.

Has resident recently been hospitalized (please explain)? *

Has resident tested positive for TB? *

Current medications *

Are you filling this application on residents behalf? *

Your Name *

First

Last

Relationship to resident *

Do you have a power of attorney/surrogate decision maker or guardianship of resident? *

Type your name as a signature *

Resident: Type your name as signature *